SMS Summer Camp 2023

Child's Name

Date of Birth

Gender

Male Female

Age as of 6/1/23

School Attending in the Fall 2023

Child's T-shirt Size

Youth XS Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult XL

City, State, Zip Code

Parent/ Guardian Information

Parent/Guardian Name 1

Parent/Guardian 1 Email

This address will receive a confirmation email

Phone

Parent/Guardian Name 2

Parent/Guardian 2 Email

This address will receive a confirmation email

Phone

If parents are divorced, who is the custodial parent?

Not divorced Mother Father

Emergency Information

Emergency Contact(s)- please list names/phone #s

Pickup Authorization- please list names/ phone #s

Does your child have any current allergies or medical/physical conditions?

List of Medications Currently Taking:

Physicians Name:

Phone

Medical Insurance Company Name:

Policy Number:

Group ID:

Permission Slip

Please check yes or no for each.

I grant my child permission to participate in all activities at Saint Matthew Summer Camp.

Yes No

I grant permission for my child to be photographed, filmed, and used in media releases.

Yes No

I understand that Saint Matthew School possesses insurance coverage. This insurance coverage is secondary to a parent's insurance.

Yes No

If Saint Matthew School decides to deny a claim, I understand that the parent/guardian is fully responsible for the medical care payment.

Yes No

I agree to participate and allow my child to participate in surveys regarding the camp program for evaluation purposes.

Yes No Parent Only

I understand that all children attending camp are required to follow all rules and regulations implemented by the summer camp staff. If an issue were to arise, I understand that the parent/guardian will immediately be notified. If the issue continues, I understand that there will be disciplinary consequences including expulsion.

Yes No

In the case of an emergency, I agree to allow the summer camp staff to notify the parent or guardian immediately. If the parent or guardian cannot be reached, I agree to allow the staff to administer treatment including the hospitalization of the child. I understand that these medical expenses will be the parent/guardians responsibility.

Yes No

I understand that all registration applications must be turned in before my child attends camp.

Yes No

By signing this form, I hereby understand and give my permission for my child to participate in all camp program activities during the camp sessions. I release and hold harmless Saint Matthew Church and School, the owners, the agents, and the participating staff from any and all liability for personal injury. I/we understand the possibility of unforeseen hazards and know the inherent possibility of risk. I/we believe that the subject of this release is physically and mentally capable of taking reasonable precautions to protect his/her own safety and has the maturity and judgment not to put themselves or others in dangerous situations. I/we agree to not hold either the Catholic Diocese of Nashville or Saint Matthew Church and School, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject. (Please type your name to serve as Electronic Signature)

Camp Sessions

Please check all camps attending! Please refer to the SMS Camp Brochure for age/grade requirements for each camp. If you would like to be added to the waitlist for a camp that has reached maximum capacity, please email the Camp Director.

Session 1: June 5th-9th Flag Football/Dodgeball HAS REACHED MAX CAPACITY Pre-K Play (9:00am-12:00pm) Cost: $140 Dance Camp HAS REACHED MAX CAPACITY Ozo Fun I (9:00am-12:00pm) Cost: $140 Stop Motion Potion I (12:30pm-3:30pm) Cost: $140 Not Attending this Week

Session 2: June 19th-23rd All Sports HAS REACHED MAX CAPACITY Pre-K Play (9:00am-12:00pm) Cost: $140 Kindergarten…Here I Come! HAS REACHED MAX CAPACITY LEGO Spike I (9:00am-12:00pm) Cost: $140 Get Your Game On! (9:00am-12:00pm) Cost: $140 Stop Motion Potion II (12:30pm-3:30pm) Cost: $140 StoryTime STEM (12:30-3:30pm) Cost: $140 Not Attending this Week

Session 3: July 17th-21st Junior Basketball (9:00am-12:00pm) Cost: $195 It's Girl Time HAS REACHED MAX CAPACITY Ozo Fun II (9:00am-12:00pm) Cost: $140 LEGO Spike II (12:30pm-3:30pm) Cost: $140 Senior Basketball (12:30pm-3:30pm) Cost: $195 Not Attending this Week

Session 4: July 24th-28th All Day Play (9:00am-3:00pm) Cost: $220 Not Attending this Week

I am interested in utilizing the Before and After Care Program. I understand that this payment will be made seperately.

Before Care (8:00-9:00am) - $10/day or $50/week After Care (3:00pm-4:00pm) - $10/day or $50/week Both Before Care and After Care - $20/day or $100/week Not interested

Payment

Please enter the total due in the "Amount Total" box. If your child is attending multiple camps, please add the amounts together and enter the total amount due in the box. If you have multiple children signed up for camp, please pay separately for each child's total due.

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

SMS Summer Camp 2023

Description

Please Fix the Following