Summer Camp Registration

Camper First & Last Name REQUIRED Please fill out this field. Please enter valid data.

Camper Date of Birth REQUIRED Please fill out this field. Please enter valid data.

Grade Entering for the 2022-2023 School Year REQUIRED Please fill out this field. Please enter valid data.

Catholic Parish REQUIRED Please fill out this field.

School for Fall 2022-2023 REQUIRED Please fill out this field. Please enter valid data.

Summer Camp Selections REQUIRED June 27-30 — Let's Celebrate! (4 Days Gr. K-5) June 27-30 — Art Intensive! (4 Days Gr. 1-5) July 11-15 — Insane Inventions! (Gr. K-5) July 11-15 — Theatre Intensive! (Gr. 4-8) July 18-22 — The Wonderful World of Disney! (Gr. K-5) July 25-29 — Step Right Up! (Gr. K-5) Please fill out this field.

Parent/Guardian 1 First & Last Name REQUIRED Please fill out this field. Please enter valid data.

Parent/Guardian 2 First & Last Name Please enter valid data.

Preferred Phone Number REQUIRED Please fill out this field. Please enter valid data.

Preferred Email Address REQUIRED Please fill out this field. Please enter valid data.

Emergency Contacts & Phone Numbers REQUIRED Please fill out this field. Please enter valid data.

Medical Information Please enter valid data.

Insurance Company REQUIRED Please fill out this field. Please enter valid data.

Policy Number REQUIRED Please fill out this field. Please enter valid data.

Preferred Hospital REQUIRED Please fill out this field. Please enter valid data.

Pick Up Information REQUIRED Please fill out this field. Please enter valid data.

Medical Release
In a medical emergency, I/we hereby authorize the school representative to obtain or administer emergency care and to seek emergency medical assistance for our child if we cannot be reached. I/We also authorize, if circumstances require, the emergency department physician to provide initial examination and treatment.

Medical Release REQUIRED I/We Agree Please fill out this field.

Photo Release
Parent/Legal Guardian of the child listed on the registration form hereby give the Archdiocese of Philadelphia, its successors and assigns and those acting with its authority, the unqualified right and permission to reproduce, copyright, publish, circulate or otherwise use any school pictures and video of my child produced by the Archdiocese of Philadelphia and Saints Simon and Jude School. This authorization and release covers the use of said pictures and video in any published form, including but not limited to newsletters, websites, social media, and any other media of advertising publicity. I also understand that our school may be identified by name and I fully understand that this is a complete release of all claims against the Archdiocese of Philadelphia or any other person, firm or corporation by reason of any such use of such school pictures. I hereby warrant that I am free to give this permission. I also understand that Saints Simon and Jude School cannot be held responsible for photographs/video recordings taken by other parents during open performances.

Photo Release REQUIRED Yes No Please fill out this field.

Camp Participation Agreement & Release
We (I), Parent/Legal Guardian of the child listed on the registration form give permission for the child to participate in the Explorers Summer Camps to which includes all related programs or events. In consideration for our (my) son’s/daughter’s participation and intending to be legally bound, we (I) and our (my) son/daughter agree and understand that we assume risk in full for our (my) son’s/daughter’s participation in the Explorers Summer Camps and with full knowledge of the risk inherent in such an activity, we release and hold harmless Saints Simon and Jude School, Saints Simon and Jude Parish, the Archdiocese of Philadelphia, and its priests, religious, teachers, aides, employees, agents, administrators, and any official representatives, from any and all liability, damages, or claims for any and all personal injury, bodily injury, and/or property damage arising or related to our (my) son’s/daughter’s participation. We (I) and our (my) son/daughter understand and agree to abide by all rules and regulations established by Saints Simon and Jude School pertaining to the Explorers Summer Camps and school code of conduct.

Camp Participation Agreement & Release REQUIRED I/We Agree Please fill out this field.