Project Serve Registration

Welcome to online registration for Project Serve! We appreciate you choosing Project Serve at Second Presbyterian Church as an activity for your child this summer. It is our prayer that they may grow mentally, physically and spiritually through this experience.

Cost per Camper:

July 9-13 – $20

Family Information

Parent or Guardian #1

Name:

Street Address:

City:

State:

Zipcode:

Phone Number:

Email Address:

Parent or Guardian #2

Name:

Street Address:

City:

State:

Zipcode:

Phone Number:

Email Address:

Emergency Contact (other than parent)

Name:

Phone Number:

Relationship to Child:

Person(s) to whom your child may be released other than Parent/Guardian:

Participant Information

Participant #1

Name:

Gender:

Birthdate:

Class in Fall:

T-Shirt Size:

Church Presently Attending:

School Presently Attending:

Allergies:

Insurance Information

Insurance Company:

Policy Holder:

Policy Number:

Family Physician:

Physician's Phone Number:

Statement of Release

My child has permission to be transported by carpool to all off campus activities. I agree that Second Presbyterian Church, and staff will not be held responsible for accidents or injuries arising from the participation in the program. I grant permission for the camp personnel to provide routine health care and to seek emergency medical care if warranted. I grant permission for my child to be included in documentation of activities or programs using video, photos, or printed materials, which may include class photos, area newspaper articles, Second Presbyterian Church Website or filmed segments to be aired on local TV stations. In consideration of my child's opportunity to participate in the program, I agree to release aand hold harmless, Second Presbyterian Church, its agents, representatives, and employees from all claims, damages, or liabilities concerning my child whihc are not the result of gross or intentional negligence or willful or wanton conduct by the program, it's agents, representatives or employees.

Parent/Guardian Signature:

Date:

Payment I will pay via PayPal/Credit Card I will pay via Check

If paying by check, make payable to: Second Presbyterian Church.

Please mail your payment to:

Project Serve
Second Presbyterian Church
3701 Old Brownsboro Road
Louisville, KY 40207