2010 Saint Peter the Aleut Orthodox Summer Camp

Monday June 28th – Friday, July 2nd

Diocese of the South ~ Southcentral Deanery

Orthodox Church in America

Camper Application

Child’s Name_______________________________ Date of Birth ______________

Address ___________________________________ Grade________ M/F________

City_______________________________________ State _______ Zip__________

Parent/Guardian_______________________________________________________

Home Phone ____________________ Work Phone___________________________

Cell Phone/s___________________________ Email Address ___________________

Emergency Contact:

___________________________________Contact Phone______________________

Any previous summer camps? (When? Where?)

Enclosed is a payment of $__________ payable to St. Seraphim’s Orthodox Church and earmarked “Summer Camp”

“Early Bird” Special $260.00	Per Camper if Paid BEFORE JUNE 7th, 2010
“Procrastinator’s Special $280.00	Per Camper if Paid AFTER JUNE 7th, 2010

SPECIAL NOTES: * Registration Cut Off Date, unless special arrangements are made: June 21st, 2010.

*  Each camper must bring $10 for food on the way to and from camp.

In addition to this registration I have completed and I am submitting the following forms:

______ Health and Medical Information and All Registration Forms

______ Camp Policy Agreement Form

Transportation information:

_____ Parent or Guardian will be bringing and picking up camper

_____ Parent or Guardian has made arrangements for camper’s transportation.

Time and date __________

  Name of person picking up camper _________________ Phone_______________ Cell #_____________

The undersigned acknowledges that, during participation at Saint Peter the Aleut Camp, at the camp site of YMCA Camp Grady Spruce,  and at other facilities used for supervised camp-related activities, certain risks and dangers may occur. These include, but are not limited to, loss or damage to personal property, physical or psychological damages and/or injury, not excluding fatality, due to accidents, which may occur. I also acknowledge that participants may be transported off the camp for supervised camp-related activities.

 In consideration, and as a part of the right to participate in this St. Peter the Aleut Orthodox Summer Camp Program, I have and do hereby assume all of the above risks and any other ordinary risk incidental to the nature of these activities which are not specifically foreseeable, and will not hold liable the Orthodox Church in America, the Diocese of the South, Saint Peter the Aleut Summer Camp, St. Seraphim Orthodox Cathedral, YMCA Camp Grady Spruce or any Camp Staff, Volunteers, Agents or Participants. I agree that any person/s providing service to the Camp, harmless from any and all liability actions, causes of action, debts, claims, and demands of every kind and nature whatsoever, whether for bodily injury, property damage or loss, which may arise in connection with any participant's activities and participation in Saint Peter the Aleut Camp.

Parent’s Signatures ____________________________________Date _______________

 ___________________________________________   Date_____________

 Please mail all registration packets and payment to: St. Seraphim Orthodox Cathedral; c/o Fr. John Anderson; PO Box 191109; Dallas, TX  75219-1109 

 Any dietary restrictions due to health or liturgical observations? Please specify: