|
I agree to abide by all camp rules.
NAME___________________________________________
AGE_____SEX_____PHONE_(_____)__________________
ADDRESS________________________________________
CITY_____________STATE_________ZIP_____________
DATE TO ARRIVE___________HOW COMING__________
DATE TO LEAVE____________HOW LEAVING__________
I assume full responsibility for this child - self - family any physical welfare and will not hold the organization liable in case of sickness, accident of any liability.
SIGNED__________________________________________
Parent or Guardian
HEALTH INFORMATION
What is the birth date? Month___ Day___ Year___
Have you had a tetanus shot or booster the last six (6) months?_____
Please indicate:
Hearing(___) Hard of Hearing(___) Deaf(___) Blind(___)
Do you have any chronic conditions such as diabetes, epliepsy, allergies, etc.? Please explain________________
________________________________________________
List physical restrictions:_____________________________
_________________________________________________
Name of your hospital Insurance Co.___________________
_________________________________________________
Plan#____________________________________________
CAMPER'S NAME__________________________________
In case of medical emergency, I understand every effort will be made to contact parents or guardians of campers. In the event I cannot be reached, I hereby give permission to the physician selected by the camp director to hospitalize and secure proper treatment for, and order injections or anesthesia or surgery for my child as named above. I also affirm that the medical information on this form is both complete and correct.
Date____________________________________________
Parent or guardian signature_________________________
Doctor's Name:__________________Phone #__________
My Phone No: Home:_____________Work:_____________
All campers that register by January 10th, we give a $10.00 discount (total is $100.00 per camper). All campers that register by May 5th with a non-refundable $20.00 registration fee. The additional $85.00 will be due upon camp arrival ($5.00 discount included) that is $105.00 total per camper. Please plan to arrive Monday afternoon for dinner and leave Saturday after breakfast.
Cost: Campers $110.00 if you want to reserve motel room $100.00 extra per room subject to availability. Cowboy cookout includes train ride up and back $1.00. Horse rides $5.00. Do not forget to bring money for snacks and gift shop.
Camper's weekly fees would be:
Recreational Vehicle Park Only: $10.00 per camper
Recreational Vehicle Park & Meals: $85.00 per camper
Dorm & Meals: $110.00 per camper
Motel & Meals: $100.00 per room plus $110.00 per camper
| 
