One Church - Joplin - Camp Wannastay 2019

Camp Wannastay 2019

Child's First Name	*
Child's Last Name	*
Child's Birthdate	*
Child's Age	*
Street Address	*
City	*
State	*
Zip Code	*
Grade child completing this year	*
Male/Female	*
Home Church	*
T-shirt Size	*
My Child is entering Kindergarten and will only be participating in Daycamp. (Drop is at 8:00am and pickup is between 7:00-9:00pm).	*
Father's Full Name
Father's Employer
Father's Cell Phone (include area code)
Mothers's Full Name
Mother's Employer
Mother's Cell Phone (include area code)
Emergency Contact Full Name	*
Emergency Contact Phone (include area code)	*
Emergency Contact Relationship	*
Child's Primary Care Physician	*
Child's Primary Care Physician Phone Number (include area code)
Current Medication(s) and/or condition(s)
Please list any limitations to your child's physical activities.
Allergies (medicines, foods, plants, bees, animals, etc)
Insurance Carrier	*
Name of Insured	*
Insurance Policy Number	*
Date of Last Tetanus Shot	*
As a parent or legal guardian, I hereby give consent to One Church Joplin and its representatives to provide all emergency treatment. I will assume all financial liability.
I have read and agree to the above medical statement.	*
My child has my permission to travel by personal/rental/church vehicles in case of emergency.	*
Please list any additional people (other than mother, father, and emergency contacts) that have authorization to pick up and drop off my child while at camp.
Please Choose the Amount in which you would like to pay.	*
Your Email Address	*

Total	$