2010 - Camp Weloki Summer Camp Registration by qIt8Xh7


									                            2011 - Camp Weloki Summer Camp Registration

Camper Information: Name _____________________________________ Date of birth___/___/___ Sex M / F
Name camper would like to be called at camp_______________ Grade (Fall 2011)_____ Age at start of camp_____
School attending next Fall: ______________________________________________________________________
Phone numbers: Home____________________ Cell: _______________________ Work:____________________
Parent/Guardian Information: Name(s) __________________________________________________________
Address: (Same as above) _______________________________________________________________________
(_____cell) _____________________ (_____cell) ___________________ (H/W/O) ________________________
E-mail address (please print clearly) ______________________________________________________________
Your email address is very important as most mail will be sent this way unless requested otherwise.

Camp Dates, Tuition & Deposit (Check your first choice of session & note a second choice)
Session 1: Sunday, June 26 - Sunday, July 3 – Location - Camp Butterfly, Farmington, MO
____ Kids Camp (this is only Kids Camp session) Tuition $995 Deposit $400.00
____ Teen Camp Tuition $995 Deposit $400.00
Session 2: Sunday, July 10 - Sunday, July 17 – Location - Camp Butterfly, Farmington, MO
____ Middle School Camp Tuition $995 Deposit $400.00
____ Teen Camp Tuition $995 Deposit $400.00
Session 3: Sunday, July 24 - Sunday, July 31 – Location - Camp Butterfly, Farmington, MO
____ Middle School Camp Tuition $995 Deposit $400.00
____ Teen Camp Tuition $995 Deposit $400.00

Terms of Payment: Space in each session is limited to ensure the best possible learning experience for
      each participant. To reserve your spot at camp send this form along with a $400 deposit. (A space cannot
      be held without a deposit, this form, including your answers to the questions on second page.)
      Deposit goes towards total tuition. Balance & all paperwork are due four weeks prior to start of

Refund/Cancellation Policy: Deposits are non-refundable. Balance is due 4 weeks prior to start of
      session. Any cancellation inside 3 weeks of camp session start date will result in loss of entire

Make checks payable to: CAMP WELOKI - 300 Chesterfield Center - Suite 255,                Chesterfield, MO 63017
                             Phone - (636) 530-1883      Fax - (636) 530-0039     E-mail: gretchen@weloki.com

Credit Card Payment: __Visa __ MasterCard __Discover
An administrative fee of 3.15% of amount credited will be added to your credit card charge .
Card number____________________________________________________________________________Exp. date______________
CID # (3 digit code on back of card) ____________ Zip code of billing address _____________________$ amount______________
___ Check here if you would like us to charge this card for the balance due 4 weeks prior to the start of the camp session

I have read and agree to the terms of payment and refund/cancellation policy.
Signature of parent or legal guardian: ________________________________________________date__________

      Please note: An e-mail will be sent to you confirming your enrollment in camp. A packet containing directions, starting and
      ending times, emergency phone number, packing list, health and medical forms and questionnaires for both the camper and
      parents/guardians to complete will be e-mailed to you approximately 6 weeks prior to the start of the sessions that you are
      enrolled. Please get your paper work in 4 weeks prior to camp so our staff will have time to review their information.
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Please answer the following questions and return to us along with the registration
page and your deposit to hold your child’s spot in camp.

In order to be sure our camp program is a good fit for your child, and as part of the protocol to reserve a spot at
camp, it is necessary to fill out this short questionnaire.

1. How did you hear about Camp Weloki?

2. What do you hope your child/teen gains by attending camp?

3. Are there any physical issues/concerns that might cause your child to not be able to fully participate in camp

4. Are there any social/emotional issues or concerns we should know about?

5. Are there any mental health diagnoses or concerns such as that apply to your son or daughter? If so, please
list them here and how they affect your child on a daily basis. It is very important to us that our camp is a good
fit for you child.

6. How did you hear about camp?
      Weloki Website ____       MomsLikeMe.com ____                              Other Website _____________
      Fox 2/STLMoms ____        KMOV/Great Day St. Louis ____                    Laude News ____
      Friend _______________    St. Louis Kids Magazine ____                     Dr. Jordan Presentation ____
      Other __________________________

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