2010 Camp Registration Form

2010 North Fork Watershed Camp

Registration Form (printable version)

Student Name ____________________________________________________________

Parent/Guardian __________________________________________________________________

Address _______________________________________________________________

City, State, Zip _______________________________________________________

School ________________________________________________________________

E-mail address for parent and student ________________________________________ 

Grade in School for 2010-2011______________________________________

Parents’ Names__________________________________________________________

Phone Number___________________________________________________________

Emergency Contact Phone (cell # if available) ________________________________

Emergency Contact Name _________________________________________________

Student’s Pertinent Allergies (i.e. food, bees, etc)________________________________

Medication that will be brought to camp _______________________________________

(Refrigeration needed for medication? __________

Swimming Ability of Child (Rating:  1-5, 5 = excellent) __________________________

(If unable to swim, please send life jacket)

I (student ) ___________________________ am committed to attend all 3 days of watershed camp (July 12,  13 &16 for ages 6-9 or July 14, 15 &16 for ages 10-14) from 1 p.m. to 5 p.m.  We grant permission for photographs to be taken of student (photos used for grant documentation of community service to the North Fork Creek).

Signature Student ________________________________________________________

Signature Parent/Guardian __________________________________________________

 Indicate here if you do not want your child photographed

Applications due July 5, 2010 with enclosed $10 check registration fee (make checks to North Fork Watershed Association)