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Who: Children going into Kindergarten thru rising 5th graders. (older youth can be volunteers)

When: Monday, June 1 - Thursday, June 4 from 9:00 a.m. - 12:00 p.m.

Cost: $50, options to attend for free are available, just ask

Activities: snacks, games, story, workshops, music and service projects

First Participant's Name
First Name*
Last Name*
First Participant's Date of Birth*
Date of Birth
Information
Preferred Name
Grade they are going into next school year (fall '24)*
T-Shirt Size (smallest size is Child's M - which seems to work each year) *
Child's Medium
Child's Large
Child's XL
Adult Small
Adult Medium
Adult Large
Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the participant bringing any medication with them (inhaler, EpiPen, etc.) ? Please describe when and how adult leaders are to administer it.
Anything special you want adult leaders to know about your child that will make them have a great week?
Friend Requests *Groups will be K-2 and 3-5, so they must be in the same age groupings. Please limit to two requests, and we will do our best to accommodate.
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Preferred Name
Grade they are going into next school year (fall '24)*
T-Shirt Size (smallest size is Child's M - which seems to work each year) *
Child's Medium
Child's Large
Child's XL
Adult Small
Adult Medium
Adult Large
Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the participant bringing any medication with them (inhaler, EpiPen, etc.) ? Please describe when and how adult leaders are to administer it.
Anything special you want adult leaders to know about your child that will make them have a great week?
Friend Requests *Groups will be K-2 and 3-5, so they must be in the same age groupings. Please limit to two requests, and we will do our best to accommodate.
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Preferred Name
Grade they are going into next school year (fall '24)*
T-Shirt Size (smallest size is Child's M - which seems to work each year) *
Child's Medium
Child's Large
Child's XL
Adult Small
Adult Medium
Adult Large
Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the participant bringing any medication with them (inhaler, EpiPen, etc.) ? Please describe when and how adult leaders are to administer it.
Anything special you want adult leaders to know about your child that will make them have a great week?
Friend Requests *Groups will be K-2 and 3-5, so they must be in the same age groupings. Please limit to two requests, and we will do our best to accommodate.
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Preferred Name
Grade they are going into next school year (fall '24)*
T-Shirt Size (smallest size is Child's M - which seems to work each year) *
Child's Medium
Child's Large
Child's XL
Adult Small
Adult Medium
Adult Large
Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the participant bringing any medication with them (inhaler, EpiPen, etc.) ? Please describe when and how adult leaders are to administer it.
Anything special you want adult leaders to know about your child that will make them have a great week?
Friend Requests *Groups will be K-2 and 3-5, so they must be in the same age groupings. Please limit to two requests, and we will do our best to accommodate.
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Preferred Name
Grade they are going into next school year (fall '24)*
T-Shirt Size (smallest size is Child's M - which seems to work each year) *
Child's Medium
Child's Large
Child's XL
Adult Small
Adult Medium
Adult Large
Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the participant bringing any medication with them (inhaler, EpiPen, etc.) ? Please describe when and how adult leaders are to administer it.
Anything special you want adult leaders to know about your child that will make them have a great week?
Friend Requests *Groups will be K-2 and 3-5, so they must be in the same age groupings. Please limit to two requests, and we will do our best to accommodate.
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Preferred Name
Grade they are going into next school year (fall '24)*
T-Shirt Size (smallest size is Child's M - which seems to work each year) *
Child's Medium
Child's Large
Child's XL
Adult Small
Adult Medium
Adult Large
Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the participant bringing any medication with them (inhaler, EpiPen, etc.) ? Please describe when and how adult leaders are to administer it.
Anything special you want adult leaders to know about your child that will make them have a great week?
Friend Requests *Groups will be K-2 and 3-5, so they must be in the same age groupings. Please limit to two requests, and we will do our best to accommodate.
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Preferred Name
Grade they are going into next school year (fall '24)*
T-Shirt Size (smallest size is Child's M - which seems to work each year) *
Child's Medium
Child's Large
Child's XL
Adult Small
Adult Medium
Adult Large
Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the participant bringing any medication with them (inhaler, EpiPen, etc.) ? Please describe when and how adult leaders are to administer it.
Anything special you want adult leaders to know about your child that will make them have a great week?
Friend Requests *Groups will be K-2 and 3-5, so they must be in the same age groupings. Please limit to two requests, and we will do our best to accommodate.
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Preferred Name
Grade they are going into next school year (fall '24)*
T-Shirt Size (smallest size is Child's M - which seems to work each year) *
Child's Medium
Child's Large
Child's XL
Adult Small
Adult Medium
Adult Large
Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the participant bringing any medication with them (inhaler, EpiPen, etc.) ? Please describe when and how adult leaders are to administer it.
Anything special you want adult leaders to know about your child that will make them have a great week?
Friend Requests *Groups will be K-2 and 3-5, so they must be in the same age groupings. Please limit to two requests, and we will do our best to accommodate.
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Preferred Name
Grade they are going into next school year (fall '24)*
T-Shirt Size (smallest size is Child's M - which seems to work each year) *
Child's Medium
Child's Large
Child's XL
Adult Small
Adult Medium
Adult Large
Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the participant bringing any medication with them (inhaler, EpiPen, etc.) ? Please describe when and how adult leaders are to administer it.
Anything special you want adult leaders to know about your child that will make them have a great week?
Friend Requests *Groups will be K-2 and 3-5, so they must be in the same age groupings. Please limit to two requests, and we will do our best to accommodate.
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Preferred Name
Grade they are going into next school year (fall '24)*
T-Shirt Size (smallest size is Child's M - which seems to work each year) *
Child's Medium
Child's Large
Child's XL
Adult Small
Adult Medium
Adult Large
Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the participant bringing any medication with them (inhaler, EpiPen, etc.) ? Please describe when and how adult leaders are to administer it.
Anything special you want adult leaders to know about your child that will make them have a great week?
Friend Requests *Groups will be K-2 and 3-5, so they must be in the same age groupings. Please limit to two requests, and we will do our best to accommodate.
Parent or Guardian's Email Address
Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Waiver Consent
Informed Consent and Acknowledgement - I hereby give my approval for my child’s participation in any and all activities prepared by Justice Camp. In exchange for the acceptance of said child’s candidacy by Broad Street Presbyterian Church, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Broad Street Presbyterian Church and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from camp session. In case of injury to said child, I hereby waive all claims against Broad Street Presbyterian Church, including all staff, volunteers, sitters, and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all activities, including camp. Mark yes to consent:*
No
Yes
Medical Release and Authorization - As Parent and/or Guardian of the named participant(s), I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named participant(s). In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to Broad Street Presbyterian Church and its affiliates including Directors, Staff, and Volunteers to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence. Mark yes to consent:*
No
Yes
In the event of an emergency and we cannot reach you, please list one additional emergency contact's name and number. *
Photo and Video Consent - We will be taking photos and videos of the Justice Camp experience. Do we and our partner organizations have your permission to use photos and videos of your child online and on social media platforms? *
No
Yes
Who may pickup your child from camp? Include their names and cell phone numbers:
How did you hear about Justice Camp?
Do you need a scholarship?*
Payments of $50 are due at time of registration. You can pay online at bspc.church/donate, by Venmo @BSPC760 (under charity tab), or by check mailed to the church. How have you paid? *
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Relationship*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
Preferred Name
Grade they are going into next school year (fall '24)*
T-Shirt Size (smallest size is Child's M - which seems to work each year) *
Child's Medium
Child's Large
Child's XL
Adult Small
Adult Medium
Adult Large
Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the participant bringing any medication with them (inhaler, EpiPen, etc.) ? Please describe when and how adult leaders are to administer it.
Anything special you want adult leaders to know about your child that will make them have a great week?
Friend Requests *Groups will be K-2 and 3-5, so they must be in the same age groupings. Please limit to two requests, and we will do our best to accommodate.
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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