Summer Registration 2017 Family Last Name*Child's Name First Last Please list all siblings attending RHUMC Summer Camps with this childChild's Gender*MaleFemaleChild's Date of Birth*Grade in Fall 2017*School*Any Allergies, Medical Conditions, or Special Accommodations?* Yes No Describe Allergies, Medical Conditions, Special Accommodations*Children's Primary Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Contact Email* Parent #1 Name* First Last Parent #1 Work Phone*Parent #1 Cell Phone*Parent #2 Name*Parent #2 Work Phone*Parent #2 Cell Phone*Emergency Contact Name*Emergency Contact Phone*List other persons authorized to pick up your child (Name and Phone):Please list the type of Sunscreen (you must provide it each day) and Child Name(s)*Check here if you have read and agree to the terms of enrollment:* Yes As the parent or authorized representative, I hereby give consent to Kid Zone of Rolling Hills United Methodist Church to obtain all medical or dental care prescribed by a duly licensed physician (M.D.), osteopath (D.O.), or dentist (D.D.S.), for the above named child. This care may be given under whatever conditions are necessary to preserve life, limb or well-being of the child named above. Photos and videos may be taken of my child for display, publicity, and in-house activities.Name of Consenting Guardian* First Last Child's Cell PhoneDo you have special requirements for sunscreen?* Yes No Unique ID This iframe contains the logic required to handle Ajax powered Gravity Forms.