UNITED METHODIST CHURCH OF WAPPINGERS
9 MESIER AVENUE SOUTH
WAPPINGERS FALLS, NEW YORK 12590
wfumcafterschoolcare.com
SUMMER CAMP REGISTRATION FORM
Camp hours 8:30 am-6:00 pm
$150.00/ Week
EARLY DROP OFF AVAILABLE FOR ADDITIONAL FEE
$10.00 Registration Fee
$50.00 Non-refundable deposit
Child’s Name ______Age ____ Early Drop Off
(Last) (First)
Date of Birth ______Allergies ______
Parent(s) Name ______
Address ______
City / State/ Zip ______
Home Phone (____) ______Cell Phone (___) ______Text Messaging
Email ______
Emergency Contact ______Relationship to child______
Phone (___) ______
Is there anything we should know about your child to help us provide the best care?
______
______
______
Session Theme Attending (Y/N)
- July 1- July 5
- July 8- July 12
- July 15- July 19
- July 22- July 26
- July 29 - August 2
- August 5 - August 9
- August 12- August 16
- August 19- August 23
- August 26 – August 30
REGISTRATION DEADLINE JUNE 7, 2019
United Methodist Church Christian Afterschool Care
Photo and Video Opt-Out Form
Dear Parent/Guardian:
The United Methodist Church Christian Afterschool Care, United Methodist Church Summer Camp will regularly publish instructional or informative text, photographs, original artwork, or other creative resources on its Internet web sites [ UMC of Wappingers controlled social media accounts, in local newspapers. Information about your child, including photographs and/or videos containing your child may be published. In addition, photos/videos of students taken throughout the school year or summer may be randomly placed on our website. We will not publish the full name of students who appear in photos and or videos unless we first receive written consent from the student’s parent / legal guardian. Should you wish to “opt-out” and NOT permit your child’s photo and/or video to be shared, please complete the form below and return it to the Director. Please note, if you permit your child’s photo/video to be shared, you do NOT have to fill out this form. If you have any questions, please call the office.
______
Photo and Video Opt-Out Form
I elect NOT to have any photos or videos of my child used in any The United Methodist Church Christian Afterschool care publications, media releases, on the website or its social media page. This form must be filled out completely to ensure that your child’s information is kept private. Please print clearly.
Child’s Full Name ______
______
Parent / Guardian Full Name (Printed)
______
Signature of Parent / Guardian
Contact Telephone Number: ______
Date: ______
PICK UP AUTHORIZATION
______
Child’s Last Name Child’s First Name M.I
______
Address
______
Primary Phone # Cell Phone # Work Phone #
______Male Female
D.O.B. Gender (Circle one)
Copy will be needed for file: Custody Orders: Yes No Orders of Protection: Yes No
I authorize the following person (s) to pick up my child when he/she is ill or at the end of the day. I also understand that once my child has been picked up by the person (s), the United Methodist Christian After School Care is no longer responsible for his/her safety.
Relationship / Contact Name / Address / Primary Phone # / Cell Phone #I give Permission to the (UMC ASC) staff to arrange for transportation of my child for emergency medical care, and for medical treatment declared immediately necessary by the physician, in the event that person(s) listed above cannot be reached. Hospital: ______