Basilica of Regina Pacis | Summer Bible Camp 2022

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First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Date of Birth REQUIRED Please fill out this field. Please enter a date.
Gender REQUIRED Male Female Please fill out this field.
Mother/Guardian REQUIRED Please fill out this field. Please enter valid data.
Phone Number (Mother/Guardian) REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Father Please enter valid data.
Phone Number (Father) Maximum 20 characters Please enter a phone number.
Email REQUIRED Please fill out this field. Please enter an email address.
Emergency Contact
1. Name
2. Relationship to child
3. Home Phone/Cell Phone
1. Name REQUIRED Please fill out this field. Please enter valid data.
2. Relationship to child REQUIRED Please fill out this field. Please enter valid data.
3. Home Phone/Cell Phone REQUIRED Please fill out this field. Please enter valid data.
Medical Concerns/Allergies REQUIRED
If none write "none"
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Is your child taking any form of medication for any reason? REQUIRED
If none write "none"
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If none of the above can be reached by phone, WHAT DO YOU WISH US TO DO in case the child is sick or injured?

(It is understood that in the final disposition of an emergency case, the judgement of the Religious Education Office Staff will prevail. The recommendation of the parent as indicated above, will be respected as far as possible.)
Response Box REQUIRED Please fill out this field.
My child can walk home alone (If they are of age 11 and above) Yes No
Address REQUIRED Please fill out this field. Please enter valid data.
LIST ANYONE WHO MAY PICK UP YOUR CHILD
1. Name
2. Relationship to child
3. Home Phone/Cell Phone
*List 1 or 2 individuals besides parents/guardians*
Response Box
LIST ANYONE WHO MAY NOT PICK UP YOUR CHILD
Response Box
T-Shirt Size REQUIRED Child M Child L Adult S Adult M Adult L Please fill out this field.
Any additional information you would like to provide about your child?
Parent/Guardian’s Consent
PLEASE READ CAREFULLY
AND ACCEPT ON THE BOTTOM
SUMMER CAMP provided by the Faith Formation Program at the Basilica of Regina Pacis, along with any/all activities associated with this week. I agree that my child is participating at his/her own risk, releasing Basilica of Regina Pacis, its trustees, employees, volunteers and agents, both now and in the future, from any accident, injury, illness or death which may occur as part of the program. In the event that my child is injured and requires emergency medical or dental treatment by a licensed practitioner, I hereby give my consent for the emergency transfer of my child to a hospital, and permission to the physician to secure proper treatment for and to order injection, anesthesia, and transporting of child. As well as to release reports necessary for insurance purposes for my son/daughter and that I will assume all financial responsibilities. It is understood that every effort will be made to contact me. I further understand that if my child is responsible for any damage done to any property, we as parents/guardians will be held responsible for my child’s actions. We grant the Basilica of Regina Pacis and its Faith Formation Program the right to take and use photos of our child in Parish’s publications and on its website.
I Accept Please select this field.
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The Basilica of Regina Pacis

1230 65th Street Brooklyn, NY 11219
718-236-0909

Summer Bible Camp 2022 - Registration