Kidz Camp Registration Child's Name* First Last Age*Date of Birth* MM DD YYYY Grade Just Completed:*K1st2nd3rd4th5thGender*BoyGirlT-Shirt Size*Youth SmallYouth MediumYouth LargeYouth X-LargeChild's Image Consent* I grant permission I do not grant permission I hereby grant/do not grant permission for my child's image to be included in pictures, videos, promotional materials, and publications connected with South River Baptist Church. Parent/Guardian Name* First Last Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Emergency Contact Information - Name, Relationship, Phone#*Does Your Child Have Allergies?* Yes No If Yes to Allergies please specifyAny special needs?Check each week you would like for your child to attend and/or if they are not attending all week, select the days they will be attending during the week.*Camps are for Boys and Girls that are rising 1st graders to graduated 5th graders. All Camps are Mon-Fri 8am-5pm and are $100 per week or $25 p/day. Early Drop-off and Pick-up is available. Camp Week 1 - June 17th-21st (all week) -June 17th (Mon) -June 18th (Tue) -June 19th (Wed) -June 20th (Thu) -June 21st (Fri) Camp Week 2 - June 24th-28th -June 24th (Mon) -June 25th (Tue) -June 26th (Wed) -June 27th (Thu) -June 28th (Fri) NO CAMP WEEK OF July 4th Camp Week 3 - July 8th-12th -July 8th (Mon) -July 9th (Tue) -July 10th (Wed) -July 11th (Thu) -July 12th (Fri) Camp Week 4 - July 15th-19th -July 15th (Mon) -July 16th (Tue) -July 17th (Wed) -July 18th (Thu) -July 19th (Fri) Camp Week 5 - July 22nd-26th -July 22nd (Mon) -July 23rd (Tue) -July 24th (Wed) -July 25th (Thu) -July 26th (Fri) Camp Week 6 - July 29th - Aug 2nd -July 29th -July 30th -July 31st -Aug 1st -Aug 2nd Who many pick up your child at the end of Summer Camp other than Parent or Guardian? List all names of those with permission.Is there a friend that your child would like be with during Summer Camp?Name of person registering child for Summer Camp*Email of person registering child for Summer Camp* Do you have a church home?* Yes No If Yes, where?