“Follow the Flame”

Registration Deadline:
Sunday, July 29, 2012

Monday, July 30th - Friday,
August 3rd
9:00 am - 12:00 pm
Kindergarten - 5th Grade

Whipple Creek Church
8802 NW 9th Ave.
Vancouver, WA 98665

Must be completed and returned to Whipple Creek Church. Please print.
Child’s Name: ________________________________ Age: ____________ Grade Entering: ______________ M / F
Parent’s Name: ____________________________________ Address: ________________________________________
City: _________________________________ State: ____________________ Zip: ______________________________
Phone: ______________________________ Email: ______________________________________________________
Home Church: ___________________________________
How did you hear about us: _________________________________________________________________________
Health History
Any medical conditions that we should know about? What are they:_______________________________________
My child has allergies to (pleae circle):



environmental (animal, plant, insect, etc.)

Describe: ________________________________________________________________________________________
Family Medical Insurance?

Yes / No

Insurance Company: ____________________________________________

My child has permission to take part in all Kids Summer Blast 2012 activities under supervision, and
I agree that the Kids Summer Blast 2012 or its personnel will not be held responsible for any
accidents. I am responsible for any medical obligations incurred during the Kids Summer Blast 2012
period and give Kids Summer Blast 2012 staff permission to seek medical treatment for my child in
case of injury or illness. I also give permission for the use of photographs including my child in Kids
Summer Blast 2012 publicity.
Parent/ Guardian Signature: _____________________________________________ Date: _______________________

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