Name of Camper
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First Name
Last Name
Camper's Email Address
*
Camper's Birth Date
MM
DD
YYYY
Camper's Grade this coming Fall
Parent 1 Name
*
Parent 1 Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent 1 Email Address
*
Parent 1 Home Phone
*
(###)
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Parent 1 Work Phone
(###)
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Parent 1 Cell Phone
(###)
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Parent 2 Name
First Name
Last Name
Parent 2 Address (if different than above)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent 2 Email Address
Parent 2 Home Phone (if different than above)
(###)
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Parent 2 Work Phone
(###)
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Parent 2 Cell Phone
(###)
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Alternate Emergency Contact
*
First Name
Last Name
Alternate Emergency Relationship
Alternate Emergency Contact Phone
*
(###)
###
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Pertinent Medical Information (allergies, medication, etc.)
Health Care Provider Name
Health Care Provider Phone
(###)
###
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Health Insurance Name
Health Insurance Policy Number of Member ID
Payment
*
We’re offering a tiered fee plan for the registration fees. You choose what you can do.
PLEASE CLICK ON THE PAYMENT OPTION YOU’RE CHOOSING AND MAKE YOUR CHECK PAYABLE TO
“COLLEGE AVENUE PRESBYTERIAN CHURCH” LABEL AS “RECREATION VBS 2019”. Please send your payment by mail to College Avenue Presbyterian Church | 5951 College Avenue, Oakland, CA 94618,
Make any checks payable to “College Avenue Presbyterian Church”
Registration is on a first come first served basis
Option One $100 - I could use a little help
Option Two $125 - I can pay what it costs
Option Three $150 - I can help cover the costs for other kids too
Not coming as a camper?
If you're not coming to VBS as a camp in what capacity do you plan to attend?
Option One - as a CIT (Counselor in Training)
Option Two - as a Counselor (1+ years of previous CIT service required)
Option Three - as an Adult Volunteer
Person or people who have permission to pick up my camper are:
Camper Release form for Liability and Media Use 1/6
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I give permission for my child to participate in all summer day camp activities sanctioned by the Recreation VBS, First Presbyterian Church of Oakland, College Avenue Presbyterian Church and for my child to leave the Recreation VBS Site accompanied by Recreation VBS staff for scheduled or spontaneous field trips. For scheduled field trips, I give permission for my child to be transported in vehicles owned and operated by the staff of Recreation VBS, as well as to go on group walking trips in the area of First Presbyterian Presbyterian Church and the Uptown District to do community gardening while accompanied by Recreation Vacation Bible School staff and volunteers. These activities will be listed whenever possible on the daily summer day camp schedule.
Yes I Agree
Camper Release form for Liability and Media Use 2/6
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I give permission for my child to be given emergency treatment, including first aid and/or CPR, by a first responder or other qualified individual, and for him or her to be transported by ambulance to an emergency center for further life-saving treatment, if necessary. In the event I cannot be contacted, I further authorize and
consent to emergency treatment for my child.
Yes I Agree
Camper Release form for Liability and Media Release 3/6
*
I give permission for photos to be taken of my child and shared electronically in order to promote VBS with marketing and photo-sharing via blog, Facebook, Twitter & Instagram for participating VBS families.
Yes I Agree
Camper Release Form for Liability and Media Release 4/6
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I acknowledge that my child will not be permitted to leave the Recreation VBS alone or with anyone else without my verbal or written permission.
Yes I Agree
Camper Release Form for Liability and Media Release 5/6
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Should something happen and my child is injured in one of the above activities or at any time or in any way while at Recreation VBS, I understand that any expenses for medical treatment including the emergency room, hospitals, doctors, etc. are primarily my responsibility— even if I choose not to have medical insurance for my family these expenses are still primarily mine as parent.
Yes I Agree
Camper Release Form for Liability and Media Release 6/6
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I agree to hold harmless, release, waive and forever discharge the Recreation VBS, College Avenue Presbyterian Church and First Presbyterian Church of Oakland its employees, officers, and volunteers from any and all claims or demands I may have by reason of any accident, illness, injury, loss, destruction or damage to property arising or resulting from my child’s participation in the Recreation VBS. I further covenant not to bring any legal against against the Recreation VBS, College Avenue Presbyterian Church, and First Presbyterian Church of Oakland, its employees, officers, and volunteers from any injury loss, or damage resulting my child’s participation in the Recreation VBS.
Yes I Agree
Signature (please type your name)
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First Name
Last Name
Today's Date (when you filled out the application)
*
MM
DD
YYYY