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M-F 9:00 - 1:00 (St Simon Parish) Extended Care (additional fee) 1:00 - 4:00

Location

Los Altos, CA

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Contact Karen Moreira:

408-638-1443

karenrui@comcast.net

First, Tell Us About Yourself:

Parent Information

Thank you for choosing St Simon VBS

IMPORTANT: Please assist us in keeping camp forms legible, Please enter ONLY ONE parent/guardian information in each cell (please do not enter multiple email addresses and phone numbers - this causes a database error). If needed, please utilize the parent/guardian number 2 name and phone number free text fields. We thank you in advance.

First Name

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Last Name

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Address 1

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Address 2

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City

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State/Province

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ZIP/Postal Code

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Contact Phone 1

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Parent/Guardian #2 Name and phone number

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Text Message Phone

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Emergency Contact Name

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Emergency Contact Relationship

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Emergency Contact Phone

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Newletter/Email Communication Email (please use 1)

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Alternate Pickup Name

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Alternate Pickup Phone

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Alternate Pickup 2 Name

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Alternate Pickup 2 Phone

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Medical Authorization: California Civil Code 25.8 provides that a parent/guardian may authorize an adult into whose custody their child(ren) is (are) entrusted, to consent to necessary medical treatment. Pursuant to these provisions, I, the undersigned, do hereby authorize St. Simon Parish to procure medical, or hospital care for the named child(ren) in the event of injury or illness while the child(ren) is(are) participating in Vacation Bible School at Saint Simon Parish. It is understood that this authorization is given in advance of any specific care required but is given to provide consent to diagnosis, treatment, or hospital care which a physician may in the exercise of his/her best judgment deem advisable. By answering 'YES' below I/We will assume financial responsibility for any care so procured.

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Illness during Camp Week: I/We understand that if our child/children exhibit any symptoms of illness, including but not limited to Covid, which are not explainable by another known underlying condition, that they will not participate in VBS until such time as the symptoms subside. Symptoms may include, Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea. In the case of fever, they have not had a fever for >24 hrs. By answering ‘YES’ below I/We acknowledge reading and understanding this policy.

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Program Participation Waiver: To the extent permitted by law, I hold the parish/school and the diocese of San Jose harmless from any claim of injury, sickness, illness or damage to property that my child(ren) may suffer or sustain during my child(rens) participation in Vacation Bible School, with exception to injury or damages arising out of the sole negligence of the Parish/School or Diocese of San Jose. I attest that my child(ren) is/are physically fit to participate in this program. In the event that that I/my child(ren) become(s) ill or injured, I do hereby consent to whatever medical treatment(s), including but not limited to x-ray, examination, or hospital care considered necessary in the best judgement of the attending physician and performed by or under the supervision of a member of the medical staff of the hospital and/or other medical facility providing the treatment. I am not aware of any medical conditions which would render it inappropriate for me/my child(ren) to participate in any activity associated with the program. By answering ‘YES’ below I/we authorize care and understand I/We may assume financial responsibility for any care so procured.

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Click here for your FREE Friends With God Kids Activity Pack

By checking the box you will be emailed your Free Friends With God Kids Activity Pack.

You are also agreeing to receive emails about family resources from Lifetree. You can unsubscribe at any time. We value your privacy. Your information will not be shared with a third party. Lifetree is a division of Group Publishing, the creators of Group VBS and other faith-building resources. Click to learn more about Lifetree.

Tell Us About Your Participant

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First Name

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Last Name

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Grade Entering

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Gender

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Date Of Birth

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Shirt Size

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Allergies

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Medical Concerns

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Do you have friends you would like to be placed with? We will do our best to group selected friends together in the same crew, but we cannot promise all requests will be possible.

Friend 1 First Name

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Friend 1 Last Name

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Friend 2 First Name

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Friend 2 Last Name

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Friend 3 First Name

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Friend 3 Last Name

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Comments

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Will this camper attend extended care (additional fee)

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Would you like to purchase (1) additional camper tshirt (additional fee)

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Does this camper currently attend St Simon School?

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Snacks: Peanut-free snacks will be provided for each day of camp. If your child requires additional accommodation, please let us know that YOU WILL provide a safe snack for him/her. Will you be providing a safe snack for this camper?

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PHOTO/VIDEO RELEASE: Photos of campers will be taken throughout the week for the purpose of end-of-camp slide show, camp newsletter and St Simon VBS private Shutterfly account. We would like to be able to use these photographs for newsletters, flyers, and the Parish Web Site. We will not use any last names if posted. Concerns about published pictures should be expressed to the writer/webmaster and will be promptly dealt with. I, the parent of this child/children, authorize and give full consent, without limitation or reservation, to St. Simon Parish to publish any photographs/videos in which my child/children and/or his/her parents/grandparents appear while participating in VBS. We understand that no compensation is to be given. Email vbs@stsimon.org if there are concerns. By completing a paid registration for camp you are acknowledging receiving and reading this photo disclaimer.

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