LUKECAMP REGISTRATION FORM

“For nothing is impossible with God.” Luke 1:37

P.O. Box 115028 – Atlanta, GA 30310
(678) 754-7700
www.thelukeproject.org

Please review calendar for a schedule of events.

Monday – Thursday, 8:00 a.m. – 3:15 p.m. for campers age 7 – 14

This permission slip covers children who attend LukeCamp via walking, van, car or bus. Note: Students are required to wait outside the building until camp begins and will need to be picked up at the conclusion of camp each day. Van riders will be picked up and dropped off per the van route and schedule.

DROP OFF 8:00 – 9:30 A.M. – PICK-UP 3:15 – 3:45 P.M.

LukeCamp | Comprehensive Summer Day camp

Please complete and fill in all blocks with information or N/A as incomplete forms will not be accepted.

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Child’s Name

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Age

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Grade

Date *

Birth date

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Home Phone

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Parents’ Names (Father)

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(Mother)

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Child’s Address

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Apt. #

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City

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Zip Code

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Parents’ Work Phone (Father)

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Parents’ Work Phone (Mother)

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Emergency Contact Name

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Emergency Contact Phone

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Relationship of Emergency Contact to child

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Family Doctor Name

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Family Doctor Phone

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Family Medical Insurance Company | (If your child’s healthcare is provided though Medicaid, Peach Care or other please write that in the blank.)

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Policy of Group Number or Medicaid / Peach Care ID - Other Number

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Date of last Tetanus Inoculation | (If this is unknown, write “unknown” in the blank.)

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Any known allergies or food allergies

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Yes

Has your child ever been stung by a bee?

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Any additional medical information that we need to be aware of

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I am sending the following medicine or medical equipment with my child

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RELEASE AND PERMISSION FOR MEDICAL CARE
I understand and agree that my child will participate in The Luke Project, Inc. d/b/a/ LukeCamp (“LukeCamp”) athletic activities and events (the “Event”) organized or sponsored by LukeCamp to be held at various locations in the area of Metro Atlanta, Georgia, or other places in the State of Georgia and neighboring states. In consideration of LukeCamp allowing my child to participate in the Event, I, for myself, my child, my heirs, executors, administrators and assigns, release and discharge LukeCamp, its employees, agents, volunteers, interns, contractors, affiliates, and representatives, and agree to indemnify them from and against any and all claims for personal injuries, property damage, losses, costs, expenses, and injuries and damages of any kind or nature suffered by my child or my child’s property as the result of or in conjunction with my child’s participation in, or traveling to or from, the Event. During the time my child is participating in the Event or traveling to or from the Event, I give LukeCamp, and its employees, agents, volunteers, interns, contractors, affiliates, and representatives, authority to seek, provide, and consent to any medical or health treatment for my child, that it or they, in their discretion, believe is appropriate. If LukeCamp or the other named persons consent to such medical treatment for my child, I ask that LukeCamp or the other named persons make reasonable efforts to contact me about such treatment.

Signature *

Parent/Guardian’s Signature

LUKECAMP REGISTRATION FORM

“For nothing is impossible with God.” Luke 1:37

P.O. Box 115028 – Atlanta, GA 30310 (678) 754-7700 www.thelukeproject.org

Monday – Thursday, 8:00 a.m. – 3:15 p.m. for campers age 7 – 14

DROP OFF 8:00 – 9:30 A.M. – PICK-UP 3:15 – 3:45 P.M.

LukeCamp | Comprehensive Summer Day camp

P.O. Box 115028 – Atlanta, GA 30310
(678) 754-7700
www.thelukeproject.org