Winter Camp Registration - Church of the Good Shepherd

Registration

Please fill out the registration form as fully as possible.

After you submit your registration form, you will be directed to a page to pay your registration fee. The fee is $20 per child. Scholarships available! Email ben.blanchard@gsnorfolk.org to inquire about scholarships.

This field is for validation purposes and should be left unchanged.

How many children are you registering?

Participant 1 Name(Required)

First Last

Participant 1 Birthdate(Required)

Participant 2 Name(Required)

First Last

Participant 2 Birthdate(Required)

Participant 3 Name(Required)

First Last

Participant 3 Birthdate(Required)

I give permission for my child (named above) to attend the events, field trips, and service projects associated with Camp Imagine of The Episcopal Church of the Good Shepherd, (Norfolk, VA). I further give permission for my child to be transported to and from events by hired and volunteer drivers authorized by The Episcopal Church of the Good Shepherd.

Medical Release
I hereby authorize the leaders, volunteers, The Episcopal Church of the Good Shepherd, hospitals, licensed medical or dental providers, and their agents and employees to have access to the information contained in this form and to provide all medical or dental care, routine tests, treatment, and necessary transportation advisable for the health and safety of my child. This authorization includes the authority to consent to any x-ray examinations, anesthetic, medical procedure or treatment, and hospital care under the supervision, and upon the advice of or to be rendered by, a physician or surgeon licensed under the Medical Practice Act or dentist licensed under the Dental Practice Act for my child.

Custody Release
I further authorize the Camp leaders of The Episcopal Church of the Good Shepherd to receive physical custody of my child upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to said adult.

Activity Release
I further give permission for my child to participate in all activities sponsored by Camp Imagine activities and The Episcopal Church Of The Good Shepherd.

Parent/Guardian Name(Required)

Typing your name here serves as your signature to this agreement.

First Last

Parent/Guardian Phone(Required)

Country Phone Number

Parent/Guardian Email(Required)

Parent/Guardian Address(Required)

Street Address Address Line 2 City State ZIP Code

Today's Date(Required)

Emergency Contact Name(Required)

First Last

Emergency Contact Address(Required)

Street Address Address Line 2 City State ZIP Code

Emergency Contact Email(Required)

Emergency Contact Phone(Required)

Doctor's Name(Required)

Doctor's Phone(Required)

Allergies/Glasses(Required)

Please list any allergies to drugs, foods, plants, insects, etc. If any participants wears contacts/glasses, please note that. (If registering multiple children, please provide separate answers for each child.)

Please list any prescription medication to be taken by the participant (including what it is taken for, when it is to be taken, dosage information, and any special procedures)(Required)

Please list any additional information relevant to participating in Camp activities (dietary needs; surgeries or serious injuries; chronic or recurring illness; medical conditions such as epilepsy or diabetes; psychiatric counseling or indications, etc.)(Required)

You have received this parental consent form to both inform you and to request your permission for your child’s photo/image and name to be published on The Episcopal Church of the Good Shepherd /or any other websites maintained, owned, and/or administrated The Episcopal Church Of The Good Shepherd or UPAC. The law requires that we ask for your permission to use information about your child. Pursuant to law, we will not release any personally identifiable information without prior written consent from you as parent or guardian. Personally identifiable information includes youth names, age, grade, and photo or image. If you, as the parent or guardian, wish to rescind this agreement, you may do so at any time in writing by sending a letter to the Director of Children, Youth and Young Adult Formation, Kim Rogers, and such rescission will take effect upon receipt.

Do you already possess Busch Gardens Seasons Pass?(Required)

Yes

Media Release(Required)

I/We GRANT permission for this youth’s photo/image and all other personal identifiers listed above to be published on the Good Shepherd/UPAC public website or any site operated by Good Shepherd or UPAC.

I/We GRANT permission for ONLY a photo/image that includes this youth without any other personal identifiers to be published on the Good Shepherd/UPAC public website or any site operated by Good Shepherd/UPAC.

I/We DO NOT GRANT permission for photo/image that includes this youth to be published on the Good Shepherd/UPAC public website or any site operated by Good Shepherd/UPAC.

Total

After you submit your registration, you will be taken to our payment page. The amount shown below is the amount you must pay in order to complete your registration.