Peace Camp Registration, 2019

August 12 - 16, Monday - Friday, 9:00 a.m. to 12:30 p.m.
Rising K-8 Grades

First Mennonite Church
601 East Parham Road
Richmond, VA 23227

Contact Information

Child's Name

First Name

Last Name

Date of Birth

Age (as of 7/1/2019)

Grade Entering 9/2019

School Attending

Parent/Guardian

First Name

Last Name

Address

Home Phone Number

Work Phone Number

Cell Phone Number

Emergency Contacts

Emergency Contact 1

First Name

Last Name

Relation to Child

Phone Number

Emergency Contact 2

First Name

Last Name

Relation to Child

Phone Number

People Allowed to Pick Up Your Child (Other Than Those Listed Above)

Pick-Up Person

This person is not already listed above, but is allowed to pick up your child

First Name

Last Name

Relation to Child

Phone Number

Pick-Up Person

This person is not already listed above, but is allowed to pick up your child

First Name

Last Name

Relation to Child

Phone Number

Health and Medical Information Insurance

Health Insurance Provider

Primary Physician

Policy Number

Check all that apply to your child, providing addtional information as needed:

Checkbox

asthma/respiratory condition

hearing impaired/deaf

unusual bleeding

diabetes

attention deficit disorder

developmentally delayed

Note any allergies your child may have and their reaction

Please provide any additional health information on your child

Medical Emergency Waiver

will be signed by parents the first day of Peace Camp.

Parent/Gaurdian Signature

By typing your name you acknowledge that the above information is correct.