Form Test Page

Parent Information
Parent First and Last Name
First Last
Phone
Email
Note:
Summer Camp Emergency Form
Best Email for Communication
Child's Date of Birth
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Father's Name
First Last
Father Place Employed:
Father Work Phone:
Father Cell Phone:
Mother's Name
First Last
Mother's Place Employed:
Mother's Work Phone:
Mother's Cell Phone:
Home Address (If different from child)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Emergency Contact
(Must not be parents. All four phone numbers must be different)
Emergency Contact Name (Contact #1)
First Last
Relationship (Emergency contact #1)
Address (Emergency contact #1)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone Number (Emergency contact #1)
Cell Phone Number (Emergency contact #1)
Emergency Contact Name (Contact #2)
First Last
Relationship (Emergency contact #2)
Address (Emergency contact #2)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone Number (Emergency contact #2)
Cell Phone Number (Emergency contact #2)
Individuals Authorized to Pick Up
Name Authorized to Pick Up & Relationship:
Name Authorized to Pick Up & Relationship #2:

Waiver Information / Right to Object
My child is allowed to participate in all materials/productions.
- Yes
- No
Please check all of the following materials/production areas that we do NOT have permission to use for your child. Please note names are never associated with pictures.
- Audio Recording
- Video Recording
- School Promotional Literature
- School website/Facebook/Instagram
- Other
Please Specify:
Note:
I agree to notify the camp within 24 hours if my child or any member of my immediate household has developed a communicable disease. I agree to notify the camp immediately if the disease is life threatening. I agree to pick up my sick or injured child within 1 hour of being contacted. If I cannot be reached, my emergency contacts can be called to pick up my child. Additionally, if I cannot be contacted in an emergency, the camp has my permission to take my child to the emergency room of the nearest hospital and I hereby authorize its medical staff to provide treatment, which a physician deems necessary for the well-being of my child.

Method of Payment
- FACTS: Please only select FACTS as a method of payment if you have an active agreement with FACTS and a current bank account active otherwise you will be charge a $20.00 fee in order to re-activate your account. By submitting this payment form and selecting FACTS you authorize St. Anthony of Padua School to divide the total cost in your remaining FACTS payments.

- Credit Card: Please issue your payment right away at the School website or visit the School Office to pay in person.

- Check: Please send your check right away with your child or stop by the School Office to pay in person.
I agree to abide by the regulations of St. Anthony of Padua School and to pay tuition and other applicable fees in a timely manner.
Select Method of Payment
- Credit Card
- FACTS
- Check/Cash
Date
Date Format: MM slash DD slash YYYY
Time

: HH

MM
Signature
Total
$0.00
Product Name
Price: $0.00 Quantity:

Saint Anthony of Padua Catholic Church