Skunk Rock Summer Registration Form

Camper’s information here:

Male
Female
Nonbinary

Camper's name: *

First

Last

Date of Birth

Age at time of camp:

Grade entering this fall: *

List all allergies and dietary restrictions:

List any medications or medical needs that apply within camp hours:

Any other information to help make your camper’s experience the best it can be:

Your information here:

Parent #1/Guardian #1 Information: (all correspondence and invoices will be sent to this person) *

First

Last

DOB

Occupation

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell phone

Do you receive text messages on this number?

Yes
No

Relationship to Camper:

Parent #2/Guardian #2 Information: (note: all correspondence and invoices will be sent to the parent/guardian named above)

First

Last

DOB

Occupation:

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell phone

Do you receive text messages on this number?

Yes
No

Relationship to Camper:

Should be contacted in case of emergency and has permission to pick up camper.

Yes
No

Emergency Contacts and Authorized Pick Up Persons: (In addition to parents/guardians)

Use this area to list the individual(s) we may contact in an emergency and/or you authorize to pick up your camper from

Name

First

Last

Relation to Camper:

Phone:

Name

First

Last

Relation to Camper:

Phone:

PARENTAL CONSENT TO TREATMENT / ACKNOWLEDGEMENT OF RECEIPT OF INFORMATION

I hereby authorize the Skunk Rock Camp Directors to provide routine health care, administer medications as ordered by a physician, obtain emergency medical treatment including radiology and laboratory studies, and arrangement of transportation for same. I agree to the release of any records necessary for medical treatment or insurance purposes. I consent to allow the physician selected by Skunk Rock Directors to secure and administer treatment, including hospitalization for the minor named above.

Signature

PRINT NAME

I understand these risks and release Skunk Rock, and the directors, trustees, officers, volunteers and employees of Skunk Rock Summer Camp from all liability for damages or injuries resulting from summer camp activity, negligence or defects in the preparation, instruction, or equipment.

Skunk Rock is not responsible for lost, stolen, or damaged personal articles.

I authorize Skunk Rock to have and use photographs, slides, videotapes, and comments of the person(s) named on this application as needed in promotional materials and public relations programming.

I individually and corporately agree to hold harmless, Skunk Rock, its volunteers, agents, employees and officers irrespective of any negligent act or omission by Skunk Rock and/or those individuals arising from or related in any way to this Skunk Rock music program.

Signature

PRINT NAME

Are you comfortable with your camper taking supervised walks to a nearby park?

Yes
No
I’d like more information

DATES CAMPER WILL ATTEND: Please select all that apply

TIMES CAMPER WILL ATTEND

Full day: 9am – 4pm
Morning: 9am – 12pm
Afternoon: 1pm – 4pm
Other, please describe below

Are you in need of extended care? Please describe below:

AGREED ON WEEKLY AMOUNT:

TYPE OF PAYMENT:

Check (Made payable to Skunk Rock LLC)
Cash
Weekly charge with card on file on every Friday of camp week.

Charge in FULL with card on file/ date of charge:

Other payment arrangements please specify:

Signature of Parent or Legal Guardian *

Date / Time

Date

Time

Questions or comments: