The Office of Vocations, Diocese of Bridgeport AND St. John Fisher Seminary Residence
Summer Camps

2009 Diocese of Bridgeport
Summer Camp Registration Form
Please fill out one form for each camper.
*Required Fields

Registration Deadline: June 12, 2009

PERSONAL INFORMATION
Camper Name*:
Street Address*:
City*:  
State*:   
Zip*:  
Parent/Guardian Name*:
Camper Date of Birth*: mm/dd/yyyy
Camper Age*:
Home Phone*: xxx-xxx-xxxx
Work Phone: xxx-xxx-xxxx
Cell Phone: xxx-xxx-xxxx
Email*:
Parish: (incl. town)

How did you hear about the Camp?

T-Shirt Size*:
           

CAMP SELECTION
Please select the camp you are registering for*:

Sequela Christi Days GIRLS Camp   OR   Quo Vadis Days BOYS Camp
       June 21 - 25, 2009                                        June 28 - July 2, 2009

Both camps will take place at the Seton-Neuman Center which is located at Immaculate High School in Danbury, CT.

PARENT/GUARDIAN PERMISSION
I, * (name of PARENT/GUARDIAN) give permission to my above-named son/daughter to participate in camp as selected above at the Seton/Neumann Retreat Center in Danbury. If needed for health reasons, I give permission for my child to be evaluated, diagnosed, treated and/or given medication in accordance with standard medical practice by licensed medical personnel. I relieve the Diocese of Bridgeport or any of its agents of all responsibility and consequences that may arise as a result of this treatment. I will not hold the Diocese of Bridgeport or any of its agents liable in the event of injury.  Further, I agree to accept any and all financial responsibility as a result of scheduling medical treatment.

My child agrees to abide by all rules and regulations stated by the Diocese of Bridgeport including but not limited to the Code of Behavior. I understand that the Diocese of Bridgeport or any of its agents will not be held liable if my child fails to cooperate with regulations, and that any infraction of the rules may result in immediate dismissal from the event at my expense.

I give permission to the Diocese of Bridgeport to photograph, videotape and/or film my child and to use his or her image in photographs, video, and/or film for the purpose of promoting the mission, activities, and programs of the Summer Vocations Camps. I understand that I and my child are not entitled to any compensation or rights in these materials, and I release the Diocese of Bridgeport or any of its agents from any liability for the use of my child’s image for the above stated purposes.

By checking this box, I/my child confirm that we have read and understand the Code of Behavior and agree to abide by these guidelines.

MEDICAL INFORMATION - * Required for Registration *
Medical Insurance Carrier: *

Insurance Id #: *

Date of Last Tetanus Shot:  * MM/DD/YYYY

Specific medical allergies, chronic illnesses or other conditions, including current medications:

Family Physician:  *     Phone:  *

Persons to contact in the case of emergency:
Name:  *     Phone:  *

Name:  *     Phone:  *

Any other comments, questions or concerns?

PAYMENT
After you submit this form electronically, please mail the $25 registration fee per camper, made out to: Office of Vocations

Please mail check to: Office of Vocations, 238 Jewett Avenue, Bridgeport, CT 06606

If financial assistance is needed, please call 203-416-1513.

ALL information requested above must be completed before submitting form, especially all medical information.