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Summer Camp 2026 Registration Form

*Parent 1: First/Last name

*Parent 1: Phone Number

*Parent 1: Email

*Parent 1: Address

*Parent 2: First/Last name

*Parent 2: Phone Number

Parent 2: Address - Leave it Blank If Same As Parent 1 Address

Child 1

*Child 1: First/Last Name

*Child 1: Date of Birth

Enter Month/Day/Year EX: 12/05/2020

*Child 1: The school grade the child finished

*Child 1: Any allergy or medical condition

Yes

No

If yes, please describe the allergy or condition.

*Is the child taking any medication on a daily basis?

Yes

No

If yes, please list all medications in the section below.

NOTE: ST. Mary summer camp will NOT administer any medication but needs to be aware in case of an emergency.

Child 2

Child 2: First/Last Name

Child 2: Date of Birth

Enter Month/Day/Year EX: 12/05/2020

Child 2: The school grade the child finished

Child 2: Any allergy or medical condition

Yes

No

If yes, please describe the allergy or condition.

*Is the child taking any medication on a daily basis?

Yes

No

If yes, please list all medications in the section below.

NOTE: ST. Mary summer camp will NOT administer any medication but needs to be aware in case of an emergency.

Child 3

Child 3: First/Last Name

Child 3: Date of Birth

Enter Month/Day/Year EX: 12/05/2020

Child 3: The school grade the child finished

Child 3: Any allergy or medical condition

Yes

No

If yes, please describe the allergy or condition.

*Is the child taking any medication on a daily basis?

Yes

No

If yes, please list all medications in the section below.

NOTE: ST. Mary summer camp will NOT administer any medication but needs to be aware in case of an emergency.

Pickup Information

*List of people who may pickup the children/s.

*List of people who shouldn't pickup the children/s.

Write N/A if not applicable.

Emergency Contact

*Emergency Contact 1

*Emergency Contact 2

Print your name to confirm the information above is correct.

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St. Mary's Coptic Orthodox Cathedral

3405 N New Hope Rd,
Raleigh, NC 27604

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