Date_____________________
Camper's Name____________________________________Age:_____ Sex: M______F______
Address:___________________________________________City________________________
State___________ZIP_________ Phone_________________E-Mail_______________________
Allergies:______________________________________________________________________
Medications:___________________________________________________________________
Immunizations(latest date) MMR______DPT_____Polio_____Tetanus_____ HEB_____ HIB_____ Chicken Pox_____ (immunization dates must be accompanied by a copy of the imunization records before confirmation) Please list any medical conditions including ADHD or any other behaviorial conditions within the last three years.______________________________ ___________________________________________________________________
Family Doctor___________________________________________Phone__________________
Must become a member by June 1, 2007 (Individual $20/ Family $45)
Waterman Member? Yes_____No_____ Camp Week (please circle weeks attending): 1 2 3 4 5 6 7 8 9
______Early drop off fee ($10 members/$20 nonmembers per week) _____Late pick up fee ($10 members/$20 nonmembers per week)
______# Camp sessions @ $100 members, $120 nonmembers
______Total Camp Fee (# sessions x weekly fee)
_____Discounts: 4 weeks = $15 deduction per child; 8 weeks = $30 deduction per child.
______Total Amount Enclosed
______check ______cash _______Visa/Mastercard
Card Number______________________________________expiration date_________________
Signature______________________________________________________________________
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.
_____________________________________________________________________________
Parent or Guardian (Please Print)
__________________________________________________________Date_______________ Signature of Parent or Guardian
Please provide an alternative contact in the event you can not be reached.
Emergency name______________________________________________Phone_________________