AGAPE SUMMER DAY CAMP

Boon Church of OCM

43-72 Bowne Street, Flushing, NY 11355
Tel: (718) 445-7640 Ext. 0
Fax: (718) 445-5323

Registration Form
_______________________ ____
Name (Last, First)
Age

___
Sex

9 /12 ____
Sept.2012 Grade

___/___/___
Date of Birth

___________________________________________________________________________________
Address
_______________ __________________
Phone Home
Business
________________________________
Family Doctor

_________________
Emergency

_______________________
Phone

No Yes _________________________________________
Allergies

/ English / Mandarin
Language at Home

Religion

/ Cantonese

/ Other

/Protestant /Church :__________________________

/Buddhist

/Muslim /Catholic

/Other ______________

? :
/Attended last year /Afterschool Program /Chinese School
How did you hear about us? AWANA /Sunday School /Newspaper /Website
* Your child/ren can be dropped off at the camp on 8:15a.m.at no charge.
* Pick up child before 5:15 p.m. /Yes ( / No Charge)
* Pick up child between 5:15-6:00 p.m. /Yes ( $2.00/child per day)

**
There will be additional charge of $5.00 for every 30 minutes for pick up after 6PM
,,

1 5

2 6
3 7
4
Total weeks

MEALS ARE FREE AND PROVIDED BY USDA THROUGH THE OFFICE OF SCHOOL FOOD AND NUTRITION SERVICES, NEW YORK CITY BOARD OF EDUCATION.

I (Parents Name), ________________________________________________, do hereby grant permission for (Students Name)

_____________________________________ to attend Agape Summer Day Camp of Boon Church of OCM. My child may go for all trips from
July 2th ~ August 17th 2012 and I take full responsibility for anything that may happen to my child. I hereby absolve Boon Church of OCM of any
legal responsibility. I agree and accept all the regulations provided by Agape Summer Day Camp of Boon Church of OCM.
Brother/Sister

Grade

1. _________________
2. _________________
3. _________________

____
____
____

____________________________

__________

Parent or Guardian Signature

Date

Office Use Only

Cash $ _________

Check # _______ $ _______

Phy. Exam A./E. T./Ph. Recipient ________________