Wintercamp Registration Form

Snow Day WINTERCAMP Registration Form

Complete and Mail to:

CBM

111 CBM Camp Road

Watauga, TN  37694


Name _________________________________

Address _______________________________

City __________________________________

State _____________  Zip ________________

Parent/Guardian ________________________

School____________________ Grade _______

Boy ___ Girl ___ Birthday ____/____/_______

IMPORTANT PHONE NUMBERS

Home _________________________________

Work _________________________________

Cell ___________________________________

MEDICAL INFORMATION

Allergies (Please List) ___________________

_____________________________________

Is there any information you feel we should know

about your child?

______________________________________

­­­­­­­­­­­­­­­­­­______________________________________

 Registration Form Continued

Special Medications

(ATTACH LIST TO THIS FORM)

 

I give my camper permission to take over the counter medication should the camp deem necessary

YES _____    NO _____

In the event of an emergency, if we are unable ot reach you, does a doctor or hospital have permission to treat your child?

YES _____ NO _____

PERMISSION FOR CAMP

I hereby give permission for my child to attend Camp Ta-Pa-Win-Go Wintercamp for the 2012 – 2013 school year.  I understand the camp carries medical insurance on all campers, but I realize that neither the camp insurance nor CBM is in any way responsible for medical treatment or liability resulting from physical conditions existing before my child attends camp.  I also understand registration constitutes permission to use my child’s picture if it appears in a video or photo.  Registration constitutes permission for my child to participate in all activities during any WINTERCAMP 2012 – 2013 activity.


________________________________________________

Parent/Guardian Signature


Other Authorized Pickup Person(s)


Name __________________________________________


Name __________________________________________

 

Name __________________________________________

Campers will ONLY be released to Parent or Guardians listed on form or Authorized Person(s) specified on THIS list

A PHOTO ID MUST BE SHOWN