Summer Camp 2018 - Registration Form

CHILD'S INFORMATION / INFORMACION DEL NINO

Full Name / Nombre Completo:

Date of Birth / Fecha de Nacimiento:

Gender/Genero:

F M

Address / Dirección:

PARENT OR GUARDIAN INFORMATION / INFORMACION DEL PADRE O GUARDIAN

Full Name / Nombre Completo:

Cell Phone / Número del Celular:

Work Phone / Teléfono del trabajo:

Email:

EMERGENCY INFORMATION / INFORMACION DE EMERGENCIA

=> Emergency Medical Release Form

Allergies (If allergic reaction occurs, please list steps to take to relieve reaction) / Alergias ( Sí tiene alergías por favor escriba cual es la reacción del nino y que pasos debemos seguir en caso de una reacción):

Other Health Problems / Otro problema de salud:

Doctor's Name / Nombre del Doctor:

Doctor's Address / Dirección del Doctor:

Phone Number / Número de Teléfono:

Health Insurance Name / Nombre de Seguro de Salud:

Policy #/ Número de Poliza:

=> Authorization for Emergency Medical Attention

In the event I cannot be reached to make arrangement for emergency medical care, I am parent/legal guardian, hereby authorize COTRK to secure emergency transportation.

Authorize

Yes No

=> Emergency Contact

Persons to contact in case of emergency if parents are not available / Personas para contactar en caso de emergencia si los padres no responden.

1. Name / Nombre:

Relationship / Relación:

Address

Phone

2. Name / Nombre:

Relationship / Relación:

Address

Phone

I understand that this child will NOT be released from COTRK to anyone except the persons named above. Names can be added or deleted at nay time. This change must be given to the COTRK office staff or child's teacher IN WRITING.

Entiendo que este nino NO saldrá de COTRK con nadie excepto a las personas mencionadas arriba. Los nombres se pueden agregar o eliminar en un cualquier momento. Este cambio debe ser dado al personal de la oficina de COTRK o al maestro del nino POR ESCRITO.

Yes No

=> Consent for Treatment

Parent consent is a legal requirement for treatment of a minor child. To authorize emergency treatment of your child in the event you are unable to be contacted, the following affidavit must be signed.

"I am parent/legal guardian, hereby authorize CHILDREN'S MINISTRY CHURCH ON THE ROCK KATY Staff Member to consent to medical treatment of my child, when I cannot be contacted. Such consent includes, without limitation, x-rays, injections, anesthetic, medical, dental or surgical examinations or treatment and or hospital care. No prior determination of life threatening emergency or danger of treatment needs to be made under this Authorization.
This authorization remain effective until July 27, 2018

YES NO

PICTURES AUTHORIZATION

I authorize COTRK Permission to post children's pictures on the website, bulletin, newsletters, or in slideshow of the church. These photos will be used exclusively for the Church and not a copy of them for extortion, disclosure or publication stranger to this institution be shared. El permiso para publicar las fotos de los ninos en el sitio web, boletín, boletines de noticias, o en diapositivas de la iglesia. Estas fotos se utilizarán exclusivamente para la Iglesia y no se compartirá copia de ellos para extorsión, divulgación o publicación ajena a esta institución.

Yes No

We are members of Church On The Rock Katy / Somos Miembros de la Iglesia Sobre La Roca, Katy?

Yes No

ATTENDANCE / ASISTENCIA

Please check the dates of each session your child will attend / Selecciones las fechas en su hijo va asistir

July 2nd - 6th July 9th - 13th July 26th - 20th July 23th - July 27th

I understand that payment must be made before the beginning of Summer Camp.  Entiendo que el pago se debe hacer antes del comienzo de la Campamento de Verano.

Yes

Summer Camp 2018 - Registration Form

Description

Please Fix the Following