Registration Form 2017 (Please complete a separate form for each child.) P.O. Box 4177 / Burlington VT 05406 / 802-338-7382 / www.camp4me.org /
[email protected]
Camp Location: Stowe High School, Stowe, Vermont Please check week(s) applying for:
[ ] Week 1: July 10 – 14 [ ] Week 2: July 17 – 21
[ ] Both Weeks
Child's Name: ____________
Birth Date:
Grade your child will enter Fall 2017_________
Age:
How does your child identify?
_______Male
_______Female
_______Other
[ ] New or [ ] Returning camper Parent 1: Address: Phone:
Email:
Parent 2: Address: Phone:
Email:
Camp fee:
$250.00 weekly charge per camper $200.00 fee for additional child in a family who attends the same week as the first child registered $25.00 additional fee for Teens (campers ages 13-17) for offsite activities
Bus fee:
$50.00 weekly charge per camper $25.00 bus fee for each additional child in family.
The cost of providing Camp For Me is estimated to be $600.00 per camper. We encourage families to consider supporting Camp For Me with a tax-deductible donation. Thank you.
Transportation:
Camp Fee: Bus Fee: Donation:
$ $ $
Total:
$
[ ] Check Enclosed
Please check the appropriate box below if your child(ren) will be riding the bus. [ ] [ ] [ ]
Bus pick-up and drop-off in Burlington Bus pick-up and drop-off in Williston Bus pick-up and drop-off in Waterbury
We encourage parents who drive their children to camp to carpool when possible. Check below if you would like us to send your contact information to other camp families in your area. [ ] I agree to share contact information with others who may be interested in carpooling. For Camp For Me use only:
Date Rec'd
Check Number
Notes
continued on page 2
Activities:What activities does your child most enjoy?
Personal History: Please list your child's strengths and challenges (physical, educational, social, emotional, and/or behavioral). Let us know how your child interacts with peers and if your child needs individual assistance with daily activities. Attach extra page if necessary. (All information is kept confidential for staff use only.)
Please check the following if applicable: Child has one-on-one attendant at school [ ] [ ] Child is enrolled in PSA Aris program (personal service attendants)
Photo Photos may be taken of your child during the week at camp, including an "all-camp" group Release: photo. Camp For Me frequently uses the photos for publicity and fundraising. [ ]
I give permission for photos of my child to be used for publicity and fundraising.
[ ]
Please do not use photos of my child for publicity and fundraising purposes. (This does not apply to all-camp photo. Please inform us if you wish your child to be excluded from the all-camp photo.)
Camp t-shirt order(included in the registration fee; please check the appropriate box): YOUTH ADULT
__ X-Small __ Small
__ Small __ Med.
__ Med. __ Large
__ Large __ X-Large
Camper Release: By signing this form, I give my child permission to attend Camp For Me and to participate in all activities as planned and supervised by Camp For Me. I recognize there are risks inherent in many camp activities and hold harmless all camp staff, including volunteers, from and against all claims and demands whatsoever on account of or in any way from an accidental occurance. I understand that Camp For Me reserves the right to dismiss at its sole discretion any camper whose conduct or behavior is deemed inappropriate or detrimental to the best interest of Camp For Me or the other campers attending. No refunds will be made for dismissal for misconduct. Camp For Me does not maintain health insurance coverage for campers. Parents or guardians shall be responsible for all medical coverage. Parents or guardians shall inform Camp For Me of the child's medical health needs and medications.
Parent or Guardian Signature:
Date:
Parent or Guardian Signature:
Date:
How did you hear about Camp For Me?(Check all that apply): [ ] Adoption agency/caseworker; [ ] Kids Vt; [ ] camp fair; [ ] Camp For Me website; [ ] flyer; [ ] word of mouth; [ ] other (explain) ___________________
