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Lake Wylie Lutheran Church
2021 Summer Camp Registration Form
Lake Wylie Lutheran Preschool
2906 Highway 160 W
Fort Mill, SC 29708
Danielle Hawkins, Director

Your Email:
Child's Name:
Enter Text:
Parent/Guardian Name:
Home Phone Number:
Daytime Phone Number:
Emergency Contact Name:
Emergency Contact Phone Number:
Individuals authorized to pick up your child:
Allergic to
Any medical condition we should be aware of:
List medical condition
Physician name
Physician Phone Number:
ALL participants for camp must be fully potty-trained.
Payment by cash or check (made out to camp teacher’s name)

Payment is non-refundable & Camp weeks are not transferable
Parent Signature:
As a parent/guardian of a Lake Wylie Preschool camp participant, I acknowledge there are certain risks of physical injury, and I agree to assume the full risk of any injuries, damages or loss which I or my minor child/ward may sustain associated with said camp. I agree to waive and relinquish all claims I or my minor child/ward may have as a result of participating in the Lake Wylie Preschool Summer Camp and their employees.
In the event of an emergency, I authorize officials of the camp to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for my minor childs/wards immediate care and agree that I will be responsible for payment of any and all medical services rendered, including transportation charges. My child/ward has no medical conditions that would prevent him or her from participating in the camp.
Verification Code:
Insert above code:
 * Required

Lake Wylie Lutheran Church • Fort Mill, SC • Church: (803) 548-5489 Preschool: 803-548-5504  © 2021