Camper Registration 2009

Document Sample
Camper Registration 2009 Powered By Docstoc
					                                              Camp Hiawatha
                                              Camper Registration
                                 Camper Name: ______________________________

Camp Session:
______ Session 1: 6/15/09 – 6/26/09; $400.00           ______ Session 2: 6/29/09 – 7/10/09; $400.00
                                     ______ Session 3: 7/13/08 – 7/24/08; $400.00

Camper’s Name: _____________________________________Birth Date: ____/____/____ Age: _______ Male Female
Address: __________________________________________________________________________________________
City: ______________________________________________State: _________________Zip: _____________________
Shirt Size: Youth S    YM     YL     YXL       AdultS      AM      AL      AXL       AXXL      AXXXL
     Two shirts are included in the cost of each camp session. Additional shirts can be purchased if desired
         from the camp store.

Father’s/Guardian’s Name: ________________________________Place of Employment: _______________________
Employment Address: _____________________________________City ________________State ______ZIP ________
Home Address (if different from camper’s): ______________________________________________________________
__________________________________________________________________________________________________
Home Phone: (________) __________________________Work: (________) ___________________________________
Cell Phone: (_________)___________________________

Mother’s/Guardian’s Name: _______________________________Place of Employment: ________________________
Employment Address: _____________________________________City ________________State _______ZIP________
Home Address (if different from camper’s): ______________________________________________________________
__________________________________________________________________________________________________
Home Phone: (________) __________________________Work: (________) ___________________________________
Cell Phone: (_________)___________________________

Emergency Contact: _________________________________________ Relationship: ___________________________
Home Phone: (________) ____________________________Work: (________) _________________________________
Cell Phone: (_________)_____________________________
Address: _________________________________________City: _________________State: ___________Zip: ________

Camp activities in which you do not wish your child to participate: ________________________________________
_________________________________________________________________________________________________

HEALTH HISTORY
Please list any allergies to plants, animals, foods, medications, or other: ________________________________________
__________________________________________________________________________________________________
Describe Reaction___________________________________________________________________________________
Date of last tetanus shot: _____________________________________________________________________________
Name of child’s doctor: _______________________________________ Phone: (________)_______________________
Does the camper require medication? _______ If so, please list:_______________________________________________
Reason(s): ________________________________________________________________________________________

Camper’s swim abilities:      None        Beginner       Intermediate        Advanced         Olympian




                                                  Office Use Only
Start date _________       Deposit _______     # of children at Camp Hiawatha _____ OCS Student? _________
                                                Camp Hiawatha
                                               Camper Registration
                                  Camper Name: ______________________________

Please circle if your child has or had the following:

Asthma
Chronic Headaches                                            Measles
Diabetes                                                     Heart Trouble
Seizures                                                     Other_________________________________________
Chicken Pox                                                  _____________________________________________
Immunization Records: Prior to attendance, you must submit your child’s immunization records.


Permission Forms:
1. Prior to attendance, you must submit a Camp Permission/Acceptance Form for camp activities.
2. Extra activities may require additional permission forms.

*Please remember to submit the $100 registration deposit ($50 for each additional child) with your registration form.

To the best of my knowledge, the information above and on all attachments is complete and correct.

Father/Guardian Signature ________________________________________ Date: ____________________

Mother/Guardian Signature _______________________________________ Date: ____________________




                                                    Office Use Only
Start date _________      Deposit _______        # of children at Camp Hiawatha _____ OCS Student? _________

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:1
posted:2/19/2012
language:
pages:2