The Church of the Good Shepherd



Good Shepherd Music Camp RegistrationAugust 6-10, 2018, 9:00 a.m. – 12:30 p.m.August 12, 2018, 9:00 a.m. – 11:30 a.m.Student NameFirst___________________ Last__________________Student Grade (2018-2019 school year, must be grades 2 to 12))_______Parent NamesFirst________________ Last________________ First_____________ Last_______________AddressParent Phone Numbers______________________________________________ ____________________________________________________________________________________Email(s)______________________________________________ ______________________________Names & Phone Numbers of Adults (Other than Parents listed above) authorized to pick up childAllergies/Medical Concerns_____________________________________________________________________________By initialing below, you indicate your understanding that your child will only be released to adults (18+) who are listed on this form, and agree with the following statements:I give permission to Church of the Good Shepherd to photograph and video record my child at Music Camp activities. I give permission for Church of the Good Shepherd to use and publish the photographs and video for any lawful purpose, including newspaper articles, church publications, and the church website.In case of emergency, I, the parent/legal guardian of the above named minor, give permission to the adult sponsors at Church of the Good Shepherd to secure proper treatment for the health and comfort of my child until I can be reached.Parent/Guardian Initials_____________________Registration Fee: $40 per child (two siblings, $60) Return Registration Form with check made payable to Church of the Good Shepherd with “Music Camp” on Memo Line. Please drop off check or mail to Music Camp, Church of the Good Shepherd, 9350 Braddock Road, Burke, VA 22015. Form can be e-mailed to musicdirector@ ................
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