Reading Camp - June 24 -26

Reading Camp is a unique opportunity for children who've completed 1st, 2nd, or 3rd grades. This is a literacy initiative of the Diocese of West Virginia and runs for three days from 9 am - noon.

Child's Full Name (and Preferred Name)

Child's Current Grade Level

Child's Birthday

Month

Day

Year

Home Address

Custodial Parent/Guardian's Name

Relationship to Child

Custodial Parent/Guardian's Email

Custodial Parent/Guardian's Phone

Other Parent/Guardian's Name

Relationship to Child

Other Custodial Parent/Guardian's Email

Other Custodial Parent/Guardian's Phone

Child's Current Medications

Child's Food Allergies

Child's Other Allergies (insects stings, environmental, etc.)

List any medical conditions we need to be aware of during this time for this child.

Medical Release Form and Permission to Treat

Check all that apply

The health history is correct and complete as far as I know and the person herein described has permission to engage in all camp activities except as noted.

I hereby give permission to the camp to provide routine first aid, administer prescribed mediations and seek emergency medical treatment including x-rays or interventions as deemed necessary.

I also grant permission to the licensed provider selected by this camp to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery as judged appropriate for the situation. I further authorize the release of medical information to any provider, insurance company and medical facility that may need access to complete their care.

I understand that if I do not have medical insurance, I, as the participant/parent/guardian, will be responsible for any medical expenses in the event of illness and/or injury.

I understand that there are risks involved in participating in camp and its activities.

Photo Release

Please Check One:

I hereby consent to and authorize the use by Christ Episcopal Church Fairmont or the Episcopal Diocese of West Virginia of any and all photographs taken during Reading Camp for the purpose of promotion, without compensation to me or my child.

I do not consent to and authorize the use of any photographs taken of my child

I hereby acknowledge that I am the parent/legal guardian of this child and the information on this application is complete and accurate to the best of my knowledge. Your printed name serves as your signature for this application.

Pick up at Noon (Corner of Gaston Avenue & 9th Street) Who is allowed to pick up this child. Name, Relationship, Phone Number