Parent/Guardian Information

Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Email*
Confirm Email*
Phone*

1st Emergency Contact - Can't be the parent/guardian

 

First Name*
Last Name*
Relationship to Child*
Phone*
Street Address*
City*
State*
Zip Code*

2nd Emergency Contact

First Name*
Last Name*
Relationship to Child*
Phone*
Street Address*
City*
State*
Zip Code*

1st Child's Information

First Name*
Last Name*
Date of Birth (mm/dd/yyyyy)*
School enrolled in during 2018/2019 school year*
Does this child have any allergies (food, bees, latex, etc): If so, please specify:*
Does this child have any special needs (disabilities, medical conditions)? If so please specify:*
Does this child take any medication regularly (Camp Noah staff will not be responsible for administering any of the medications)? If so, please specify:*
Dates that this child will not able to attend Camp Noah and Reason*
This Child's last day of school is (mm/dd/yyyy):*

2nd Child's Information

First Name
Last Name
Date of Birth (mm/dd/yyyy)
School enrolled in during the 2018/2019 school year
Does your child have any allergies (food, bees, latex, etc): If so, please specify:
Does your child have any special needs (disabilities, medical conditions, etc.)? If so, please specify:
Does your child take any medication regularly (Camp Noah staff will not be responsible for administering any of the medications)? If so, please specify:
Dates that this child will not able to attend Camp Noah and Reason
This Child's last day of school is:

3rd Child's Information

First Name
Last Name
Date of Birth (mm/dd/yyyy)
School enrolled in during the 2018/2019 school year
Does your child have any allergies (food, bees, latex, etc): If so, please specify:
Does your child have any special needs (disabilities, medical conditions, etc.)? If so, please specify:
Does your child take any medication regularly (Camp Noah staff will not be responsible for administering any of the medications)? If so, please specify:
Dates that this child will not able to attend Camp Noah and Reason
This Child's last day of school is (mm/dd/yyyy):

Camp Noah Agreement with Guardians

  1. I am applying to have my child(ren) attend the Camp Noah half day summer camp that meets Monday—Friday from 1pm – 4:45pm. I understand that placement is restricted to students who have completed the 1st – 7th grades, is not guaranteed, and is limited.
  2. I also understand that if my child will be absent from Camp Noah I must tell/call Camp Noah to inform them of the absence before the start of program that day. If I do not do that, it will be considered an unexcused absence.  I understand that Camp Noah reserves the right to remove children who accumulate more than 3 unexcused absences or over 6 total absences.
  3. I further understand that my child(ren) may be sent home or removed from Camp based on conduct deemed to be inappropriate by the Camp Noah staff and volunteers.
  4. I am responsible for getting my child(ren) to and from the program safely.
  5. I understand that Camp Noah uses lessons that are Biblically based and that my child(ren) will be exposed to and will participate in Christ-centered activities.
  6. I understand that registration is not complete until I have turned in a copy of my child’s physical from within the last 2 years.

By checking the box below I permit my child to participate in Camp Noah activities & programs. Additioanally it confirms agreement with the above statements, that all information provided on this form is complete and accurate, and releases Camp Noah, Hartford City Mission (HCM) and all of HCM’s staff/volunteers of any liability.

Camp Noah Agreement*
  • Yes

Transportation Release

During Camp Noah, your child may go on field trips to various sites within the state of Connecticut. These field trips will enhance your child's learning!  All field trips will have an appropriate number of chaperones.  Children will be transported in vehicles that have been certified by the State of Connecticut as a Camp Vehicle and/or on a school bus by a licensed school bus driver.  If our trip is in walking distance we will walk together as a group.

 

By checking the box below you have my permission to transport my child in all the above methods.  I release Camp Noah staff and/or volunteers from any liability.

Transportation Release*
  • Yes

Photo and Video Release

During the Camp Noah programming, I understand that my child may be photographed or recorded on video to be used for memorabilia and future program promotion.

 

By checking the box below, you have my permission to photograph or videotape my child for inclusion in newspapers or for reasons stated above, or to display samples of her/his work.

Photo and Video Release*
  • Yes
Additional Comments

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