Summer Camp Registration

Preschool Summer Camp Registration
CLEMMONS FIRST BAPTIST PRESCHOOL
PO Box 279
CLEMMONS, NC 27012

* Indicates required field

Child's Name (Last, First, Name Used) *

Sex *

Male Female

Date of Birth *

Age *

Parents'/Guardians' Names *

Street Address *

City, State, Zip Code *

Home Phone # *

Cell Phone # *

E-mail address *

Food Allergies? *

Numbers and names to call if your child becomes sick or in case of emergency during Preschool hours.

1. Phone #, Name and Relationship *

2. Phone #, Name and Relationship *

3. Phone #, Name and Relationship *

Doctors: Name / Phone *

In the event that my child has a medical emergency and the staff is not able to reach any of my emergency contacts, I give permission to the staff of Clemmons First Baptist Church Preschool to treat my child. If 911 is called and hospital treatment is necessary, I want my child transported to:

Name of Hospital *

Insurance Name and # *

Signature of parent/guardian *

Date *

Submit