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St. Luke Summer Day Camp – Registration
985-641-6429 Fax: 985-847-0742
Email: [email protected]
(A $40.00 per family Non-Refundable registration fee must accompany each registration form)
Parent’s Name:________________________ Mother’s Cell:_______________ Father’s Cell_______________
Address: _________________________ ________ City: _____________ Zip Code:__________
Parent’s (or guardian) place of employment: Mother_____________________ Phone:______________
Father _____________________ Phone:_______________
Campers must have written permission from a parent or guardian to leave camp with an
individual other than the custodian.
My child/children are under the custodial care of: ___Both parents ____Mother only _____ Father only _____
____ Other (Please specify) __________________________
In Case of emergency, if parents cannot be reached, please contact:
Name: ____________________________________ Relationship: ______________________
Work Phone: ___________________ Home or Cell Phone: _______________________
Camper Information:
Family Doctor: ____________________________ Phone #: _________________
Have all of the children listed on this form had a tetanus shot in the last five years? ______
1st Camper: _____________________ _________Age: ____ __ Date of Birth: ___/___/___ Sex: ______
# of Weeks Attending: 1st__ _ 2nd___ 3rd___ 4th ___ 5th ___ 6th___ 7th___ All 7 ___
Prohibited Activities? _____________________________ _______ School Attending:_____________________
Please list any allergies, disabilities, physical or emotional limitations your child’s counselor
should know about: ___________________________________________________________________
Camper will bring medication to camp: Yes ___ No ___
Name of medication: ___________________
Camper May take Acetaminophen (Tylenol): Yes___No__ _Camper may take Pepto-Bismol: Yes __ No
2nd Camper: _____________________ _________Age: ____ __ Date of Birth: ___/___/___ Sex: ______
# of Weeks Attending: 1st__ _ 2nd___ 3rd___ 4th ___ 5th ___ 6th___ 7th___ All 7 ___
Prohibited Activities? _____________________________ _______ School Attending:_____________________
Please list any allergies, disabilities, physical or emotional limitations your child’s counselor
should know about: ___________________________________________________________________
Camper will bring medication to camp: Yes ___ No ___
Name of medication: ___________________
Camper May take Acetaminophen (Tylenol): Yes___No__ _Camper may take Pepto-Bismol: Yes __ No _
3rd Camper: _____________________ _________Age: ____ __ Date of Birth: ___/___/___ Sex: ______
# of Weeks Attending: 1st__ _ 2nd___ 3rd___ 4th ___ 5th ___ 6th___ 7th___ All 7 ___
Prohibited Activities? _____________________________ _______ School Attending:_____________________
Please list any allergies, disabilities, physical or emotional limitations your child’s counselor
should know about: ___________________________________________________________________
Camper will bring medication to camp: Yes ___ No ___
Name of medication: ___________________
Camper May take Acetaminophen (Tylenol): Yes___No__ _Camper may take Pepto-Bismol: Yes __ No __
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