St. James the Greater Catholic Church 2024 Summer Camp Registration, Permission, and Medical Release Form The Camp Coordination Staff requests that this form be received no later than May 24, 2024 in order to facilitate ease of planning and processing. Space permitting, registrations will be accepted up to ten days prior to the start of your activity. Please complete a separate form for each child. Payment may be mailed or dropped off at the Parish Office or St. Zita’s.
Part I: Registration and Payment Name of Camper:
Home Phone:
Age:
Date of Birth:
Last School Grade Completed:
Gender:
Parent 1 Name:
Work/Cell Phone:
Parent 2 Name:
Work/Cell Phone:
Address:
City/State/Zip:
E-mail Address:
T-Shirt Size:
Emergency Contact Name and Number:
Date of Last Tetanus Shot (for Webster Springs Attendees only):
In consideration of the wholesome recreational and learning experience in which my son/daughter will participate, I, as parent or legal guardian of my son/daughter do hereby agree to allow my son/daughter to participate in the following event(s): (Check all that apply):
Total Amount Enclosed:
Method of Payment
Link for Online Payment (copy and paste in browser):
https://www.eservicepayments.com/cgi-bin/Vanco_ver3.vps?appver3=Fi1giPL8kwX_Oe1AO50jRoSeuJ1NuQVt4mnYsNaSGaES2zfZgdvtsgHvl4ll5gbek0PpduXvnt8gXUeZjQYbn_1y9rOOvABExUEiIcnKloU=
**{For those parents who wish to volunteer to help all week at a camp, we will offer a ½ price camp fee for that camp to your child(ren)}**
Scholarship Request: Each camp annually has limited scholarship funds available to assist campers to attend camp(s) based on financial need. We ask that parents requesting scholarships, both full and partial, sign up to help at the camp at which they request a scholarship or for another camp. Just as the parents who pay for these camps must choose the camps their children can attend based on their family budget, we ask those requesting scholarships to base their requests in the same way. We cannot grant a scholarship for every child for every camp, but we will do our best to ensure that the scholarships are granted equally so that every child who needs assistance has the opportunity to attend at least one or two camps of his/her choice.
Scholarship Request Type:
Scholarship volunteer type:
Camps volunteering for (Or Email Address for Prayer Partner):
Each family will receive an email letting you know that your child(ren) has/have been registered. You will also receive an email if you request a scholarship letting you know if we were able to grant the scholarship request. (Please send any questions to vcre@stjameswv.org or call 304-725-5558 x231.)
Part II: Permission and Medical Release In consideration of the opportunity for my son/daughter to participate in this program, I agree to RELEASE AND HOLD HARMLESS AND INDEMNIFY the Roman Catholic Parish of St. James the Greater, 49 Crosswinds Drive, Charles Town, WV 25414; the Roman Catholic Bishop of Wheeling-Charleston and his successors, a Corporate Sole; and all their agents, servants, and employees from any and all liability, claims, demands, and causes of action arising out of or relating to any loss, damage, or injury sustained in connection with or arising out of my son’s/daughter’s participation in the program.
I hereby grant permission to any staff to obtain medical care from a licensed physician, hospital, or medical clinic for my son/daughter in the event I cannot be reached.
(Click one of the following):
Insurance Policy Number (if applicable):
Insurance Policy Issued By (if applicable):
I hereby grant permission to any staff person to provide the following over-the-counter medication to my son/daughter if needed and requested by my son/daughter (circle all that apply):
Please note any other medical information concerning medication, allergies, disability, illness, etc:
Please note any dietary restrictions:
Parents/guardians of participants are advised that photographs or videotape of participants may be used in publications, websites, or other materials produced from time to time by the Roman Catholic Parish of St. James the Greater (participants will not be identified without specific written consent).
Parents/guardians who do not wish their child(ren) to be photographed or filmed should so notify the parish in writing. Please note that the parish has no control or responsibility over the use of photographs or film taken by media that may be covering the event in which your child(ren) participate(s).
We reserve the right to refuse and/or rescind acceptance of any registration or camper at any point if we believe he/she is unsuitable for our programs for any reason including: health, physical ability, or behavioral history.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. Name:
Date:
