Chaperone Registration Form by 04t6jy

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									HEART OF VIRGINIA COUNCIL                                                                               For Council Use:
ARROHATTOC DISTRICT                                                                                       Acct. Code
CUB SCOUT DAY CAMP
                                                                                                            GL 8103
July 31 – Aug 4, 2012                   Scout Registration Form
                                 Registration Deadline: Friday, June 15, 2012
                • MUST complete an Annual Health and Medical Record form (parts A & B).

  Scout Information: (PLEASE PRINT CLEARLY AND FILL OUT COMPLETELY)
  Age at July 25, 2012 _________     Rank as of Sept 2012 ________________
  First Name: ________________________ Last Name: _________________________ Pack #: _______
  Address: ____________________________________________________________________________
  Emergency Contact Name: ______________________________ Relationship: ____________________
  Phone #: ___________________________
  Please indicate below a phone number and email address for general camp related contact information (ie- severe
  weather causing camp to close, reminders about camp, etc)
  Name: ____________________________________              Phone #: ______________________________

  [Email—preferred contact] __________________________________________________________________

  T-shirts will NOT be guaranteed if application is received after the Registration Deadline.
  Circle shirt size:     Youth Medium     Youth Large     Adult Small      Adult Medium     Adult Large     Adult XL


  CUB SCOUT AGREEMENT: (CUB MUST READ, UNDERSTAND AND SIGN)
  Upon signing this Agreement…
  I will follow the Buddy System while in Camp. I will know where my Buddy is at all times.
  I will not leave Camp, while Camp is in session, without the Directors permission.
  I will ask for permission from the Chaperone leader before I leave the Den.
  I will not bring knives or matches to camp.
  I will be respectful to all Staff members and all Chaperones.
  I will be respectful and mindful of the feelings, safety and property of other campers.
  Proper language will be used at all times.
  I WILL HAVE FUN.
  I have read and understand this Agreement, and I understand that failure to abide by these rules could lead to a
     phone call to Parents or possible dismissal from Day Camp.


  Scout’s Name: (print) _______________________________________
  Scout’s Signature:          _______________________________________
  Parent’s Signature:         _______________________________________ Date: _______________

    For Pack Coordinator Use:
         I will attend camp for _______ day(s) as a  Cub (new Tigers, Wolves and Bears),  Webelos (I or II)
         I will attend on the following days:
           FULL WEEK or            ONLY the checked days:
                                     Tuesday, Wednesday, Thursday, Friday, Saturday




    For Office Use Only:       Parent is a Chaperone      Staff         assigned to ____________________________
    Free T-shirt & water bottle: Y N

    Docs rec’d (list date)   Reg Form: ________     Med Form: __________    DB Entry: _____________/_____

								
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