KidsPark Summer Camp 2023 Registration Child's Name* First Last Grade Completed*Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeShirt Size* Allergies* Week 1 | [June 5-9]$125.00 Week 1 (June 5-9) Week 2 | [July 24-28]$125.00 Week 2 (July 24-28) Week 3 | [July 31 - Aug 4]$125.00 Week 3 (July 31 - Aug 4) Parent/Guardian's Name* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Emergency Contact* First Last Emergency Contact Phone*Names of those authorized to pick child(ren) up* If my child is injured, please:****Please note that if a child is in an emergency situation, we will call 911 first. Call me first about treatment Call 911 first I give permission of my child's photograph to be used for APLBC public media and website:* Yes No Participant Permission*I hereby authorize and give my permission for my child(ren) to participate in activities located at the church and on church property. Activities include, but are not limited to, games, recreation activities, waterslides, playground equipment, and inflatables. I understand the church and volunteers will supervise my child and provide a safe environment, recognizing that accidents may happen. I herby authorize my permission for my child(ren) to participateAuthorization for Emergency Treatment*I hereby give permission to the staff and volunteers of Avon Park Lakes Baptist Church to consent to X-rays, tests, treatment, anesthetic, medical, or surgical, diagnosis or treatment, and necessary transportation for my child. In the event of an emergency, if I cannot be contacted I hereby give permission to the physician selected to administer treatment, including hospitalization for my child. I will pay the cost of any such medical procedure or treatment. I hereby release and waive all claims against Avon Park Lakes Baptist Church, its employees, representatives, and chaperones related to this on-site activity. This permission form has been signed only after understanding and considering all the information set forth above. I agree to emergency treatmentTotal $0.00 Credit CardCard Details Cardholder Name Δ