Registration

For all children entering kindergarten through the completion of sixth grade (age 12).

First Name*
Last Name*
Entering Grade*

Please check all of the weeks in which your child will participate:
There is an additional $20 non-refundable registration fee for each child registered.

Weeks Attending*

T-shirt Size (select one). Children who are registered prior to June 10th will receive the size ordered. After June 10th t-shirt sizes will be based on availability.

Shirt Size
Registration Fee*
 $ 
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Child’s Date of Birth:*
Child’s Home Address:*
Phone Number:*
-
Family Church Affiliation (if any):

How to Reach Parent/Guardian During Super Summer Hours 

Parent 1 (required)

Parent 1 Name:*
Parent 1 Address:*
Parent 1 Phone:*
-

Parent 2

Parent 2 Name:
Parent 2 Address:
Parent 2 Phone:
-

How to Reach Pediatrician or Source of Health Care

Physician Name:*
Physician Address:*
Physician Phone:*
-

Emergency Contact Person(s)

Contact 1 Name:*
Contact 1 Address:*
Contact 1 Phone:*
-
Contact 2 Name:
Contact 2 Address:
Contact 2 Phone:
-

Please list allergies or medical conditions of which the staff should be aware.
Enter None or N/A in the next two fields if your child has no medical issues or doesn’t require medication.

Medical Conditions*
Daily Medications*
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In consideration of the opportunity for my child to participate in Super Summer, I hereby agree to indemnify and defend New Colony Baptist Church and cooperating congregations, as well as officers, employees, chaperones, representatives, and volunteers thereof, from: 1) all liability for any property damaged by, personal injury to, or loss of consortium of my child, and 2) all liability whatsoever, arising from any acts or omissions of my child.

We have read the policy for discipline at Super Summer. The expectations for behavior are understood, as well as the consequences. We agree to abide by both.

By signing this registration form, I am granting New Colony Baptist Church, and other ministries associated with this Super Summer activity the right to use any images taken during Super Summer related activities to be used for internal and promotional purposes. 

Emergency Medical Treatment

I also hereby give my permission for the Super Summer staff of New Colony Baptist Church to administer basic first aid and/or CPR to my child and/or take my child to a hospital for medical attention when I cannot be reached, or when a delay could be dangerous to my child’s health.

Signature of Parent/Guardian*
Date*
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