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Unbound Grace Summer Kids Camp Registration Form
4118 VT RT 116 Starksboro, VT | (802) 377-1066 | UnboundGrace.org | facebook.com/UnboundGrace
Classical Horsemanship July 9-12 | Orienteering & Maps July 23-26 | Musical Theater August 6-10
Ages 6 - 17
Farm-Based Learning for Active, Healthy Kids

Please contact Kerry@UnboundGrace.org with any questions about this registration form, how to get financial assistance to help with the cost of the program, or questions about our farm and educational programs in general.

Email address *
Camper
Camper's Name *
Your answer
Camper's Birthdate *
MM
/
DD
/
YYYY
Camper's Age *
Your answer
Camper's Gender *
Camper's dietary restrictions *
Camper's School Name *
Your answer
Camper's Hobbies
Your answer
Parent/Guardian Contact Information
(1) Parent/Guardian First *
Your answer
(1) Parent/Guardian Last *
Your answer
(1) Parent/Guardian Workplace(s)(for primary household) *
Your answer
(1) Parent/Guardian Phone Number (Home) *
Your answer
(1) Parent/Guardian Phone Number (Cell)
Your answer
(1) Parent/Guardian Phone Number (Work)
Your answer
(1) Parent/Guardian Email Address
Your answer
(1) Parent/Guardian Physical/Mailing Address *
Your answer
(1) Parent/Guardian City/Town *
Your answer
(1) Parent/Guardian Zip Code *
Your answer
(2) Parent/Guardian First Name (Only if camper has multiple households)
Your answer
(2) Parent/Guardian Last Name
Your answer
(2) Parent/Guardian Workplace
Your answer
(2) Parent/Guardian Phone Number (Home)
Your answer
(2) Parent/Guardian Phone Number (Cell)
Your answer
(2) Parent/Guardian Phone Number (Work)
Your answer
(2) Parent/Guardian Email Address
Your answer
(2) Parent/Guardian Physical/Mailing Address
Your answer
(2) Parent/Guardian City/Town
Your answer
(2) Parent/Guardian Zip Code
Your answer
Emergency Contact Information – Alternate Pickup/Release
(1) Emergency Contact First Name *
Your answer
(1) Emergency Contact Last Name *
Your answer
(1) Emergency Contact Phone Number (home) *
Your answer
(1) Emergency Contact Phone Number (cell) *
Your answer
(1) Emergency Contact Phone Number (work) *
Your answer
(1) Emergency Contact email address *
Your answer
(1) Emergency Contact relation to child *
Your answer
(2) Emergency Contact First Name
Your answer
(2) Emergency Contact Last Name
Your answer
(2) Emergency Contact Phone Number (home)
Your answer
(2) Emergency Contact Phone Number (cell)
Your answer
(2) Emergency Contact Phone Number (work)
Your answer
(2) Emergency Contact email address
Your answer
(2) Emergency Contact relation to child
Your answer
Please list those people in addition to parents/guardians who are permitted to pick up your child:
Your answer
Medical Information
Physician Name *
Your answer
Physician Address *
Your answer
Physician Phone Number *
Your answer
Health Insurance Provider *
Your answer
Any known allergies, previous injuries, or other physical or medical conditions: *
Your answer
Any other medical info about the camper: medication that may need to be checked in with Camp Counselors, etc.:
Your answer
I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. (Parent/Guardian Initials indicate consent.) *
Your answer
I understand that Unbound Grace will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. (Parent/Guardian Initials indicate consent.) *
Your answer
Additional Info
Please indicate how you heard about the Unbound Grace Summer Kids Programs. *
Your answer
Previous riding experience (if any): *
Your answer
Week(s) you're interested in attending: *
Required
Any other info about the camper: learning differences, mental/emotional conditions, comments/concerns re: caregiving, learning: *
Your answer
Terms of Agreement
I hereby give permission for my child to be photographed during the Unbound Grace Summer Kids Program. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of Unbound Grace. (Parent/Guardian Initials indicate consent.) *
Your answer
I hereby give permission for the transportation of my child for official Unbound Grace activities by modes of transportation agreed to by the camp organizers. (Parent/Guardian Initials indicate consent.) *
Your answer
Unbound Grace and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. Children's’ photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician). (Parent/Guardian Initials indicate consent.) *
Your answer
To complete your registration, please send us your $50 registration fee.
Please mail your registration fee of $50 per camper to Unbound Grace, PO Box 8, Starksboro VT, 05487. Your registration won't be complete until we receive your registration fee in the mail.

Thank you so much for your interest in the Unbound Grace Summer 2018 Programs!

A copy of your responses will be emailed to the address you provided.
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