Child's Birthday & Age
Last Grade
E mail Address
Full Address:
physical & mailing
Cell Phone
Home Telephone
Home   Church

EMERGENCY INFORMATION in case a parent cannot be reached:
Name, Phones, relationship to child:
Person responsible for pick up at the end of each CSC day:
Name, Phone numbers
Please list any allergies, medical conditions or information the directors need to
know about your child:
PICK YOUR TOP THREE ACTIVITIES, and number your favorites as 1
for first, second choice as 2, and third choice as 3.
BASKETBALL (all ages) Group limit: 10 Kids
Playing basketball and practice drills in the gym!
MUSIC/DRAMA (ages 7-12) Group limit: 10 Kids
Fun with singing and exploring drama!
DULCIMER (ages 7-12) Group limit: 10 Kids
Learn to play the Mountain Dulcimer-you don't need to
read music. Dulcimers and music provided.
RECORDER (ages 6-12) Group limit: 6 Kids
Learn to play tunes on the recorder-you don't need to
read music. Recorders and music provided.
ART  (ages 7-12)  Group limit: 10 Kids
Go home with new artistic skills and art pieces!
CHESS (all ages)  Group limit: 10 Kids
Learn to play chess, the most popular game in the
BAKING (all ages) Group limit: 8 Kids
Learn to prepare yummy baked good, and some
YOUNGER ADVENTURES (ages 4-6) Group limit: 10 Kids
Join the fun! Art, science, music, games!
I agree that pictures taken throughout CSC with my child in them can
be used for publicity purposes.
I will not hold Our Savior Lutheran Church, any of its workers or
volunteers responsible for any injuries received during CSC.
I understand there may be times my child will get wet during CSC
and I DO allow my child to participate in these events.
Parent's or Guardian's Signature Acknowledement for CSC:
Our Savior Lutheran Church

Christian Summer Camp
Tuesday, June 11  to Thursday, June
6:00 to 8:00 p.m.
CSC is for children age 5 through 12.