2019 Girl's 2 Night Camp Out
1580 King Mill Road Four Oaks, NC 27524 919-938-1776 nc@campflintlock.com
Email address *
Session *
Camper Name (First, Middle, Last) *
Your answer
Camper Preferred Name *
Your answer
Date of Birth *
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DD
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YYYY
Current Grade Level *
Your answer
Waist Measurement *
Your answer
Waist to Ankle Measurement *
Your answer
Teammate request (is there another camper that your camper would like to be on the same team with).
Your answer
Is there another camper/sibling that your camper would NOT like to be teamed up with?
Your answer
Father's Name *
Your answer
Mother's Name *
Your answer
Who is the primary contact person/custodian? *
Your answer
Primary Phone Number *
Your answer
Secondary Phone Number *
Your answer
Tertiary Phone Number *
Your answer
Primary Mailing Address *
Your answer
Secondary Mailing Address
Your answer
Family/Primary Care Physician *
Your answer
Physician's Phone Number *
Your answer
Year of Last Tetanus Shot
Your answer
Are there any special needs, medical conditions or behavioral conditions Camp Flintlock should be aware of to ensure your child's camp experience is a positive one? Please check all that apply *
Required
Please elaborate upon any answers stated above, or put N/A. *
Your answer
Any other restrictions or relevant previous injuries? Include any dietary restrictions. *
Your answer
Camp is $145.00 per camper with an additional $25.00 refundable security deposit. The security deposit is to cover possible costs of damaged or lost company property. If your camper returns all of our equipment in good conditions then you will receive a refund of $25.00. Otherwise the cost will be taken out of the deposit and the remaining money refunded to you. *
Minimum Payment Due Today: $70.00 *
How would you like to pay? *
I agree to pay all costs including the participation fee ($145.00), refundable security deposit ($25.00) and any other charges that may be incurred. *
Required
I agree that I and the Camper will follow and abide by the rules and policies of Camp Flintlock. *
Required
I grant Camp Flintlock permission to take whatever actions in its judgement may e necessary to supply emergency medical services to the above mentioned camper. Camp Flintlock agrees to make every effort to contact the parents/guardian in the case of such a situation. *
Required
I agree to be solely responsible for any expenses the may be incurred for medical treatment for the Camper *
Required
I understand that some of the activities provided by Camp Flintlock may incur risk of injury, and hereby release Camp Flintlock, its employees and volunteers from any liability from injuries that may occur. *
Required
I agree to reimburse Camp Flintlock for any damages to or loss of company equipment incurred by the Camper *
Required
Please email Camp Flintlock a recent picture of the camper and your the front and back of your health insurance card. Email to campflintlockinc@gmail.com *
Required
By typing your FULL NAME below you are in effect singing this registration form, agree to the above authorizations and verify that the information given is complete and accurate to the best your knowledge. *
Your answer
A copy of your responses will be emailed to the address you provided.
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