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Pioneer Life Camp Registration Form Summer 2017
Camper's Name *
Your answer
Parent or Guardian's Name *
Your answer
Complete Mailing Address *
please include zipcode
Your answer
Primary phone number *
Your answer
Email address (if available)
Your answer
Grade that camper will enter in Fall 2017 *
Camper's birthdate
Your answer
Camper's gender
Return Camper?
If yes, list previous summers (years) attended
Your answer
Please indicate session you are registering for *
Please indicate transportation option *
Clothing Size *
shirt size for boys; dress size for girls
Your answer
T-shirt size
Emergency Contact *
Please list name, best number to reach person and relationship
Your answer
Additional Emergency Contact
Please list name, best number to reach person and relationship
Your answer
Please list name of any individual who is NOT authorized to pick up your child
Your answer
Does the camper have any physical condition which we should be aware? This includes food and/or medicine allergies, hyperactivity, learning disabilities, behavior disorders, or medical conditions.
Your answer
Does the camper require special attention, medication or routines that may have to be taken into consideration during the daytime?
Your answer
Please list any concerns that you or your child would like us to be aware of.
Your answer
Preferred Physician
Name and phone number
Your answer
Preferred Hospital *
Health Insurance Information
Insurance company and policy number
Your answer
Permission is granted for my child to be photographed during his/her attendance at the Pioneer Life Day Camp programs. This consent released liability all personnel of the State of Illinois, the Illinois Historic Preservation Agency, Lincoln's New Salem State Historic Site, the New Salem Lincoln League and Illinois College and any others who have received permission to take photographs during the Pioneer Life Day Camp programs. This consent also gives permission for photographs taken to be used in publicity or publications for the State of Illinois, the Illinois Historic Preservation Agency, Lincoln's New Salem State Historic Site, the New Salem Lincoln League and Illinois College. *
Required
Permission is granted for the Pioneer Life Day Camp programs, Lincoln's New Salem State Historic Site, and Illinois College to post camp pictures that include my child on their respective Facebook pages. Full names of campers will not be used when posting pictures. *
Required
Camp handbooks are available online to either download or print. There are separate handbooks for Walking in Lincoln's Footsteps and Living History Apprentice, so please select the appropriate handbook. If you would like us to send you a printed copy of the handbook, please indicate below.
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