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Join us for a second year at our Catholic Kids Camp! 2015 Counselors and Adult Volunteers

DATES: Monday June 22- Friday June 26, 2015 TIMES: 8:30AM – 12:15PM LOCATION: St. Thomas the Apostle R.C. Church Corporation Parish Center Building 208 East Avenue Norwalk, CT 06855

Participant Name: ____________________________________________________________________

Age (if 12-17 years): __________ Shirt Size: ________

Parent Name (if 12-17): _______________________________________________________________

Address: ____________________________________________________________________________

City: _______________________________________ State: _____________ Zip: _________________

(circle one) (circle one)

Day Phone: __________________ Guardian/ Participant: ________________________ Home/ Cell

(circle one) (circle one) Other Phone: __________________ Guardian/ Participant: ______________________ Home/ Cell

Do you or your child need special accommodations? If so, please explain:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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Please check all that apply:

_____I am interested in being a Group Leader. (Lead Counselor in a group of campers)

_____I am interested in being a Station Leader. (i.e. crafts, bible stories, etc.)

_____I am interested in providing one-on-one help to a child with special needs.

_____I am interested in working with pre-schoolers.

_____I am interested in working with 1st - 3rd graders.

_____I am interested in working with 4th – 5th graders.

Note: Indicating interests does not guarantee placement in those areas. ATTENTION Mail all forms to: St. Thomas the Apostle R.C. Church ATTN: VBS Registration 203 East Avenue Norwalk, CT 06855

Food Allergy Alert! I am allergic to _______________________________________________________________

_____________________________________________________________________________.  

Do you use an epi-pen? _______________________________________________________

Are you able to self-administer? ________________________________________________  

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St. Thomas the Apostle R.C. Church Corporation 2015 Catholic Kids Camp

Photo Permission and Release Form

I hereby give permission to St. Thomas the Apostle R.C. Church Corporation (referred to as “St. Thomas”) and the Diocese of Bridgeport and its agents and representatives to take photographs, make artistic renderings, and or make film, video or audio recordings of me or my child (whose name is set forth below) while s/he is participating in camp-sponsored activities for so long as s/he is at Camp. In addition, I hereby give permission to St. Thomas to use such photographs, renderings, film, video and audio recordings in perpetuity for any purpose and in any manner it deems appropriate by the STA, in any media, including, without limitation, print, video and web-based uses. I understand that such use may include, without limitation, use in connection with school yearbooks, newsletters, brochures, websites and promotional materials. I understand that St. Thomas and the Diocese of Bridgeport has complete editorial discretion with regard to use of such photographs, renderings, film, video and audio recordings and that I will not be compensated in any way for any such use. I release and forever discharge St. Thomas and the Diocese of Bridgeport, its affiliates, officers, agents, representatives and successors from any claims, costs, liabilities and or expenses arising from any use of such photographs, renderings, film, video and audio recordings, including, without limitation, any claims of invasion of privacy, defamation, violation of publicity rights, and hereby hold St. Thomas the Apostle R.C. Church Corporation and the Diocese of Bridgeport and its agents harmless from and against such claims.

Name of Counselor or Adult Volunteer: ________________________________________________

Signature of Participant (if 18+) or Parent/Legal Guardian: ________________________________

Printed name of Parent/Legal Guardian (if applicable): ___________________________________

Address of Participant (if 18+) or Parent/Legal Guardian: _________________________________

_____________________________________________________________________________________

Date: __________________________