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Student Name *
Student Name
Student Birthdate *
Student Birthdate
Student Phone *
Student Phone
Please provide IEP to
Parent/Guardian Phone *
Parent/Guardian Phone
We want you to know that while your student is at the United Methodist Church of the Palm Beaches, we will take every precaution to ensure his/her safety. In the event of an emergency, we will attempt to reach you or an approved guardian. If all attempts to reach someone fail, we need your permission to seek medical attention for your student.
I hereby grant permission and authorize designated adult leaders of the United Methodist Church of the Palm Beaches Summer Camp staff to make emergency medical decisions on behalf of said student in the event that I the parent or legal guardian cannot be contacted or located.
I agree that my insurance company will be used for such medical care and I am aware that I will be billed for any medical care not covered by my insurance company.
Photo Release
Photographs are often taken during the summer programming and events. By checking this box, you are agreeing that The United Methodist Church of the Palm Beaches and Through the Roof Ministries have the rights to use the student's photo on our website, Facebook, and Instagram. The United Methodist Church of the Palm Beaches needs permission from you, the parent or legal guardian, to publish (in print or online) videos/photos/images your student. This includes print materials published by UMCPB (bulletin, newsletter, brochures) and/or UMCPB related websites (our church’s Facebook page, the Through the Roof Ministries Facebook group, and/or the church's website). *
You will be receiving an email confirmation from You will need to fill out some forms in order to be registered for this summer camp including a STAR Portal Referral form for VR.