EMERGENCY INFORMATION:

DOCTOR LAST NAME: DOCTOR FIRST NAME: DOCTOR PHONE

NUMBER:

RELATIVE NAME: RELATIONSHIP: RELATIVE PHONE

NUMBER:

OTHER EMERGENCY RELATIONSHIP: PHONE NUMBER:

CONTACT:

INSURANCE COMPANY: POLICY OR GROUP

NUMBER:

LIST ANY
RESTRICTIONS:
ALLERGIES TO DRUGS
OR FOODS:

IN THE EVENT THAT YOU ARE UNABLE TO REACH ME DURING ANY EMERGENCY,
YOU ARE AUTHORIZED TO RELEASE MY CHILD TO ANY ONE OF THE ABOVE
PEOPLE, OR TO TAKE MY CHILD TO A HOSPITAL EMERGENCY ROOM TO BE
TREATED.

I HEREBY GIVE PERMISSION FOR MY CHILD TO PARTICIPATE IN ALL CAMP FIELD

TRIPS AND ACTIVITIES.

MOTHER’S SIGNATURE: _________________________________________

FATHER’S SIGNATURE: _________________________________________

 CAMPER INFORMATION:

CAMPER’S NAME GENDER BIRTHDAY AGE SCHOOL ATTENDED

SESSION(S) ATTENDING (PLEASE CHECK):

FULL DAY: HALF DAY (18MO-3YRS):

SESSION 1 $850 SESSION 1 $450
SESSION 2 $850 SESSION 2 $450
BOTH SESSIONS $1600 BOTH SESSIONS $800
EXTENDED CARE $(ask) EXTENDED CARE $(ask)

Total amount agreed upon $_______________

REGISTRATION PAYMENT OF $100 MUST BE ATTACHED TO SECURE A SPACE

FOR YOUR CHILD.

PARENTAL INFORMATION:
MOTHER’S INFORMATION FATHER’S INFORMATION
NAME:
ADDRESS: (INCLUDING
CITY, STATE, ZIP CODE)
EMAIL:
HOME PHONE:
BUSINESS PHONE:
CELL PHONE: