Rollstone Church Day Camp
199 Main Street, Fitchburg, MA 01420
8:45 AM to 3:00 PM (including bus ride times)
9:00 AM to 2:30 PM (if meeting us at camp)
June 20 – June 24, 2011

Please deliver by hand or mail this application (with payment) on or before May 31^st ** to the
Day Camp Director or a member of the Board of Christian Education located at the above address.

Separate applications must be filled out for each aplicant.
Children must be between the ages of 5 through 13 as of June 1 The cost per camper is $30.00
Please make checks payable to Rollstone Church Day Camp.

Child's name_________________________________________________

Age as of June 1^st______________________ Current Grade________________________

Parent(s) Name(s) _____________________________________________________________

Daytime phone #_____________________Work or Cell Phone#_______________________

Parent E-Mail address ___________________________________________________________

Any health problems or allergies_________________________________________________

Is your child planning to take the bus? Yes__________       No_____________

If your child is not riding the bus daily, please specify alternative arrangements

Persons authorized to pick up your child:

Name: ______________________ Phone#________________Relationship:____________

Name: ______________________ Phone #_______________ Relationship:____________

If you are not a member of Rollstone Church, who referred you to camp?

Name: ____________________________________________.

PERMISSION SLIP

I hereby grant permission for my child to participate in all Day Camp events, trips, swims, etc.
that are normally a part of this Day Camp program.

In case of an emergency in which I cannot be reached, please contact the following person:

Name: _______________________ Phone #______________Relationship: ______________

I give permission to the Day Camp Director to take necessary steps should medical attention, emergency treatment, and/or hospitalization be required.

Parent/Guardian Signature_________________________________ Date_______________