*Camper Registration Form*
PART A
CHILD________________________________________________________________________BIRTHDATE___________
LAST FIRST INITIAL M/D/Y
ADDRESS____________________________________________________________________________________________
NUMBER STREET CITY ZIP
HOME PHONE___________________________PARENT�S E-MAIL___________________________________________
* * * * * * * * * * * * * * * * * * * * * * * E M E R G E N C Y I N F O R M A T I O N * * * * * * * * * * * * * * * * * * * * * *
MOTHER__________________________HOME PHONE_____________________CELL PHONE___________________
NAME OF EMPLOYER_____________________________________WORK PHONE___________________________
EMPLOYER ADDRESS______________________________________________________________________________
FATHER____________________________HOME PHONE_____________________CELL PHONE_________________
NAME OF EMPLOYER______________________________________WORK PHONE__________________________
EMPLOYER ADDRESS______________________________________________________________________________
* * * * * * * * * * * ** * * * * * * * A L T E R N A T E E M E R G E N C Y C O N T A C T * * * * * * * * * * * * * * * * *
NAME_________________________________________RELATIONSHIP TO CHILD_____________________________
HOME PHONE______________________WORK PHONE______________________CELL PHONE_________________
* * * * * * OTHER THAN PARENTS, ONLY THE FOLLOWING MAY PICK UP MY CHILD * * * * * * * * * * * * * *
1. __________________________________________________RELATIONSHIP TO CHILD_________________________
2. __________________________________________________RELATIONSHIP TO CHILD_________________________
3. __________________________________________________RELATIONSHIP TO CHILD_________________________
4. __________________________________________________RELATIONSHIP TO CHILD_________________________
SUMMER ADVENTURE CAMP for KIDS 2003
*Medical & Health Information*
PART B (ALL BLANKS MUST BE FILLED IN)
NAME OF DOCTOR_______________________________________TELEPHONE________________________________
NAME OF DENTIST_______________________________________TELEPHONE________________________________
NAME OF HEALTH PLAN_______________________________PLAN NUMBER________________________________
FOOD ALLERGIES____________________________________________________________________________________
MEDICAL ALLERGIES________________________________________________________________________________
DOES YOUR CHILD HAVE SPECIAL NEEDS?___________________________________________________________
(USE ADDITIONAL PAPER IF NECESSARY)
In case of a life threatening or dental emergency, I authorize S.A.C.K. to do the following:
_____ Take the child to the Emergency Hospital for emergency treatment.
_____ Contact doctor/dentist and get instructions.
_____ Contact parent/emergency contact to obtain instructions.
____________________________________________________________________DATE____________________________
Signature of parent/legal guardian
****************OFFICE USE ONLY***************************OFFICE USE ONLY**********************
REGISTRATION RECORD
JUN 09-JUN 13_____EC_____CHECK#_______CHECK$_________CASH$_________BALANCE DUE$______________
(S1W1)
JUN 16-JUN 20_____EC_____CHECK#_______CHECK$_________CASH$_________BALANCE DUE$______________
(S1W2)
JUN 23-JUN 27_____EC_____CHECK#_______CHECK$_________CASH$_________BALANCE DUE$_____________
(S2W1)
JUN 30-JUL 04_____EC_____CHECK#_______CHECK$_________CASH$_________BALANCE DUE$______________
(S2W2)
JUL 07-JUL 11_____EC_____CHECK#_______CHECK$_________CASH$_________BALANCE DUE$_______________
(S3W1)
JUL 14-JUL 18_____EC_____CHECK#_______CHECK$_________CASH$_________BALANCE DUE$_______________
(S3W2)
JUL 21-JUL 25_____EC_____CHECK#_______CHECK$_________CASH$_________BALANCE DUE$_______________
(S4W1)
JUL 28-AUG 01_____EC_____CHECK#_______CHECK$_________CASH$_________BALANCE DUE$______________
(S4W2)