All fields are mandatory |
Child's Name |
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Child's Age |
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| Child's DOB |
(MM/DD/YYYY)
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| Child's Sex |
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| Camp Week |
The Great Outdoors Week, June 13
Time Travel Week, June 20
Cross Country Trip Week, June 27
Holidays Week, July 5 ($180)
Pirate Week, July 11
Superhero's Week, July 18
Amazing Race (Around the World) Week, July 25
Leadership Week, August 1
Water World Week, August 8
Mystery Week, August 15
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Camp Choice |
Youth (Entering 2nd-3rd Grade)
Junior (Entering 4th-5th Grade)
Senior (Entering 6th-7th Grade)
CIT (Entering 8th-9th Grade)
Scuba Camp (12-17 Years Old)
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| Extended Care Required? |
Yes
No |
| Mother's Name |
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| Mother's Phone |
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| Mother's Employer |
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| Mother's Email |
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| Father's Name |
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| Father's Phone |
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| Father's Employer |
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| Father's Email |
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| Child's Address, City, State & Zip |
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| ICE (In case of Emergency) Name |
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| ICE Phone |
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| Child's Primary Physician |
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| Physician Phone |
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| Hospital of Choice |
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We do not provide sickness/accident insurance for camp participants. Therefore, it is each participant's responsibility to be covered by his/her parent's hospitalization policy AND provide the required information to Dutch Springs to be used in the event of an emergency. |
| Insurance Company |
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| Policy Number |
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| Policy Group |
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| Please List any allergies |
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| Please list any health limitations |
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| Please list any physical limitations |
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| Is your child allergic to bee stings? |
Yes
No |
| PLEASE READ |
Once we receive this registration for AND your $50.00 deposit, you will receive two documents that must be read, signed and returned (or brought the first day of camp). Once document is a general release of liability (waiver) and the other is a Medical Emergency Permission Form. |
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| Electronic Signature (Type full name) |
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| Date |
(MM/DD/YYYY) |
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