Course(s)/Camp(s): 

                  

Student Name: 

Current School: 

Entering Grade: 6789101112

Gender:  FemaleMale

Mailing Address: 

City, State and Zip: 

Parent Email Address (required for all correspondence): 

Emergency Information

Parent 1: 

Phone: 

Employer: 

Phone: 

Parent 2: 

Phone: 

Employer: 

Phone: 

Media Release

Occasionally we take photos or video footage during class for use in our catalog and other public media.  Do we have your permission to use your child's image? Please chooseYes, you have my permissionNo, please do not use images

Emergency Medical Information Release

I hereby authorize the staff of St. Mary's Academy Summer Program to act for me according to their best judgment in any emergency requiring medical attention.  I hereby waive and release the St. Mary's Academy Summer Program staff from any and all liability for any injuries sustained by my child while at camp.  I have no knowledge of any physical impairment that would be affected by the above named child's participation in this program. *Please send any special needs, dietary restrictions, or allergies that you feel we should be aware of to admissions@stmaryspdx.org.

Emergency Contact: 

Emergency Contact Phone: 

Medical Insurance Carrier:

Policy Number:

Parent/Guardian Name (Signature): 

 

Security Measure