• • Date
    
    
• • Parent's Name
    
    First
    
    Last
• • Address
    
    Street Address
    
    Other Address (optional)
    
    City
    ...AlabamaAlaskaAlbertaArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew BrunswickNew HampshireNew JerseyNew MexicoNew YorkNewfoundlandNorth CarolinaNorth DakotaNova ScotiaOhioOklahomaOntarioOregonPennsylvaniaPrince Edward IslandQuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYukon Territory
    State/Province
    
    Zip/Postal Code
    
    Region (optional)
    ...United StatesCanadaJapanUnited KingdomAustraliaGermanyFranceSwitzerlandItalyNetherlandsAlbaniaAlgeriaAmerican SamoaAndorraAnguillaAntarticaAntigua & BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBotswanaBouvet IslandBrazilBritish Indian Ocean Terr.Brunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslColombiaComorosCongoCook IslCosta RicaCote D'IvoireCroatiaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEstoniaEthiopiaFaeroe IslandsFalkland Isl. (Malvinas)FijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern Terr.GabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey C.I.GuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslHondurasHong KongHungaryIcelandIndiaIndonesiaIrelandIsle of ManIsraelItalyJamaicaJapanJersey C.I.JordanKazakhstanKenyaKiribatiKorea Republic ofKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLiechtensteinLithuaniaLuxemborgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslMartiniqueMauritaniaMauritiusMexicoMicronesiaMoldova Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherland AntillesNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslNorthern Mariana IslNorwayOmanPakistanPalauPanamaPanama Canal ZonePapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts & NevisSaint LuciaSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSt. HelenaSt. Pierre and MiquelonSt. Vincent & GrenadinesSurinameSvalbard & Jan Mayen IslSwazilandSwedenSwitzerlandTaiwanTajikistanTanzania United RepublicThailandTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslTuvaluU.A.E.U.S.Minor Outlying IslUgandaUkraineUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican City StateVenezuelaViet NamVirgin Isl (British)Virgin Isl (U.S.)Wallis & Futuna IslandsWestern SaharaYemen Republic ofZaireZambiaZimbabwe
    Country
• • Phone Number
    
    
    
    
    
    
• • Cell Number
    
    
    
    
    
    
• • Email
    
    
• • Child's Name
    
    First
    
    Last
• • Grade Completed in 2012-2013 School Year
    ...Kindergarten1st2nd3rd4th5th6th
    
• • Birth Date
    
    
• • Home Church
    
    
• • T-shirt Size
    YM
    YL
    AS
    AM
    AL
    
• • Preferred Sport
    ...BasketballSoccer1/2 day VBS only
    Your child will participate in a Sports Crusaders Skill Camp. Please choose one sport. Kindergarteners may only participate in soccer. BASKETBALL FOR 3-6 GRADE IS FULL! PLEASE CHOOSE SOCCER. Thanks!
• • Hours of Participation
    Before Care 7:30-8:15
    Whole day- VBS & Sports Crusaders 8:30-4
    Half Day VBS only- K-2 am, 3-6 pm
    Half Day Sports Crusaders only- 3-6 am, K-2 pm
    After Care 4:15-5:30
    Check all that apply. There is no additional fee for before or after care. VBS only is free.
• • Health and Safety Notes
    
    Please let us know of any medical or allergy information (snacks and lunch served) , security concerns, or behavioral notes we need to care for your child. Also list any medications and dosage to be given by camp staff.
• • I agree that my child
    1. has had all immunizations required for public school.
    2. is able to participate fully in physical activity.
    3. Should receive medical attention at my expense if deemed necessary by the camp or church staff and that I release and discharge Memorial Baptist Church and Sports Crusaders from all claims, demands, damages, actions, causes of action and liability for any and all personal injuries and/or damages to my child and/or my child's property relating to my child's participation in VBS and Sports Crusaders to the extent those injuries and damages arise from the negligence or fault of Sports Crusaders or Memorial Baptist Church.
    4. Can be videotaped or photographed in a decent and appropriate manner to be used for promotional materials, slide shows, videos or any other nonprofit endeavor of Sports Crusaders or Memorial Baptist Church.
    5. is under parental supervision at Family Day.
    
• • Preferred Hospital
    
    
• • Emergency Contact
    
    First
    
    Last
• • Emergency Phone Number
    
    
    
    
    
    
• • Parent initials
    
    I represent and certify that my child's participation in Sports Crusaders, VBS, and Family Day is voluntary and recognize that my child assumes risks related to his/her participation in Sports Crusaders, VBS, and Family Day activities. I CERTIFY THAT I HAVE READ AND THAT I UNDERSTAND THE FOREGOING APPLICATION, REQUEST AND RELEASE.
• • Parent Signature (to be signed the first day of camp.)
    
    Please leave blank for now.
• • Date of Signature
    
    Please leave blank for now.

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