Registration Form 2021 – Capen Hill Nature Sanctuary

Child's Name*

First Last

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 upload immunization record below.

File

Please upload a copy of your child's immunization record if you have not sent it in. Thanks

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 ( July 5-9)
Session 2 ( July 12-16)
Session 3 ( July 19-23)
Session 4 (July 26-30 )

Explorer Price Per Session (5-13 years)*

Price: $200.00 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.

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

2021 Capen Hill Science and Nature Camp Registration Form