Capen Hill Science and Nature Camp 2019 Registration Form

Please fill out the form below. One form per camper. You can upload an immunization record which is required for camp. Thank You! If you choose to mail a check the address is Attn: Barb Frederick, Capen Hill Nature Assoc, Inc. P.O. Box 218, Charlton City, MA 01508

2019 Capen Hill Science and Nature Camp Registration Form (1)

Child's Name*
First Last
Gender*
Age at Start of Camp*
Years Months Grade in September

Please list as whole numbers.
Parent 1
First Last
Parent 2
First Last
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Contact Home Phone Number
Contact Cell Number
Contact Work Number
Contact Email Address
Enter Email Confirm Email

Please include your e-mail address. Thank You
Emergency Contact*
First Last
Relationship to Camper*
Emergency Contact Number*
Emergency Contact Number 2
Medical History: To help us understand your child's individual needs, please write here any medical information that we should be aware of such as peanut or bee sting allergies, nosebleeds, headaches, etc.*
Before your child starts camp, we need a copy of his/her immunization record. Form may be mailed to Capen Hill Nature Sanctuary, P.O. Box 218, Charlton City, MA 01508 or emailed to barbhfrederick@gmail.com. You may also bring the copy of immunizations on the first day of camp!
Does child need medication while attending camp? If yes, a form will be sent to you to fill out.*
Does child have an inhaler or EpiPen? If yes, a form will be sent to you to fill out.*
Parent's and/or Doctor's suggestions/restrictions:
Doctor's Name*
First Last
Doctor's Phone Number*
Please Check Session or Sessions for your child.*
- Session 1 ( 8-12)
- Session 2 ( July 15-19)
- Session 3 ( July 22-26)
- Session 4 (July 29-August 2 )
Fledgling Price Per Session (Member: 4-5 years)
Price: $100.00 Quantity:
Fledgling Price Per Session (Non-Member: 4-5 years)
Price: $120.00 Quantity:
Some 5 year olds may be ready for a full day camp. If this is your child you may pay below as an explorer.
Explorer Price Per Session (Member: 5-12 years)
Price: $130.00 Quantity:
Explorer Price Per Session (Non-Member: 5-12 years)
Price: $150.00 Quantity:
Camp T -Shirts $12 Each
- Child Small (6-8) Tends to run small.
- Child Medium (10-12)
- Child Large (14-16)
- Adult Small
- Adult Medium
- Adult Large
- Adult X-Large
T-Shirt Cost
Price: $12.00 Quantity:
Visor
Price: $10.00 Quantity:
One size fits all.
Additional Information about child placement in groups or any misc. notes you would like to tell us!
If you would like your child to be placed with friends or siblings of same approximate age, please write information pertaining to this in the box. It helps us out now then to try to place friends together when groups are already designated. If we have a question, we also will contact you. Thanks for your cooperation.
File
Please upload a copy of your child's immunization record if you have not sent it in. Thanks
Parental Permission Waiver*
- I Accept
- I Don't Accept
I hereby authorize the staff of Capen Hill Nature Sanctuary to act for me in accordance with their best judgement in any emergency requiring medical attention. I understand that the director of the camp may, if necessary for my child's health, have him/her hospitalized or use outside medical, surgical or dental care. I hereby waive and release Capen Hill Nature Sanctuary for expenses incurred due to sick illness or accidental injury sustained while participating in camp activities. I also understand that the director and/or camp leaders may dismiss my child from Capen Hill Nature Camp, if, in their opinion his/her conduct or influence is not in the best interest of the entire group. No refund is given if such action is taken for discipline reasons.
Total Payment:
$0.00
How Would You Like To Pay? Click on first or second choice.*
Choice One is Paypal or Credit Card. Credit card payment is under the Paypal Login. Choice 2 is Send a Check

Years	Months	Grade in September