Destiny Summer Adventures Registration Form

Child Information

Name of Child:

Select One:

Male

Female

Birth Date:

Religious Affiliation or church that you attend:

School District of Residence:

Known Allergies:

Parent Information

Parent's Name:

Relationship:

Home Phone:

Cell Phone:

Email:

Address:

Street Address Address Line 2 City State ZIP Code Country

Mother's Employer:

Work Phone

I authorize the following people to pick up my child in case of an emergency:

Emergency Contact Name:

Relationship:

Home Phone

Cell Phone

Work Phone:

Emergency Contact Name:

Relationship:

Home Phone

Cell Phone

Work Phone:

Digital Signatures

The above information is current and up to date. I agree to notify Destiny Christian School & Preschool of any and all changes to the above information as soon as the changes occur.

Mother's Signature

Father's Signature

In case of a medical emergency, I hereby authorize the Destiny Christian School & Preschool Staff to seek professional medical help. It is understood that all possible mean will be used to notify me before this is done. I also understand that any medical expenses incurred will be my responsibility.

Mother's Signature

Father's Signature

Destiny Summer Adventures is a comprehensive 9 week program, and due to only 60 available openings participants are required to attend all nine weeks (emergencies and illnesses withstanding).

Camp price per week is $130 with a $45 per week wrap-around option that allows child care from 7:30 am - 9 am, and 3 pm - 5:30 pm. Weekly payments are due each Friday for the following week of service.

Please log into FACTS to create a payment plan. Payments will be automatically deducted.

Child's Name	Birthday (mm/dd/yyyy)	Current Grade

Destiny Summer Adventures Registration Form

Child Information

Parent Information

I authorize the following people to pick up my child in case of an emergency:

Digital Signatures

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