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WATERMAN Summer Camp

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Registration Form

Child's Name__________________________________________ M/F (Circle)
Address____________________________________________________________
City____________________________________ State_______ Zip__________
Home Phone#________________________________________________________
E-mail Address_____________________________________________________
Age____ Date of Birth________ Grade completed as of June 2010 _____
Parents'/Guardians' Names__________________________________________
Other numbers where parents/guardians may be reached (work, cell, etc.)
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ALTERNATIVE CONTACT - for emergency and you cannot be contacted:

Name/Relationship__________________________________________________
Phone Number(s)____________________________________________________

MEDICAL INFORMATION

Dates of last immunizations: (please provide a copy also)
MMR___________ DPT___________ Polio__________ Chicken Pox__________
Tetanus_______ Hep B_________ HIB____________
Allergies:(Please write "none" if no allergies)____________________
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MEDICATIONS List below, with doses and times 
(Please write "none" if child does not take any medication.)

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MEDICAL CONDITIONS (including ADHD) 
(Please write "none" if no medical conditions exist.)

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Physician name and number__________________________________________
Insurance name and policy__________________________________________

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WATERMAN Summer Camp

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Permission Form

Camp Permission Form

I give my permission for _____________________________________to take part in the Summer Day Camp Program at Waterman Conservation Education Center.  This child, to the best of my knowledge, is in good physical condition and is capable of hiking through the Waterman Center trails.  I understand that hiking and other activities associated with an outdoor camp have an inherent risk factor, and that all appropriate precautions will be taken for the safety of my child.  I give my permission to the Waterman Center staff and volunteers and/or hospital staff to administer proper medical assistance to the above named participant.  I agree not to hold the Fred L. Waterman Conservation Education Center, Inc. or any of their agents responsible in the event of injury to my child.

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Parent or Guardian (Please Print)

__________________________________________________________Date_______________
Signature of Parent or Guardian

Payment Form