Khalsa Camp Registration Form 2024
Please fill out this Registration Form and send in your non-refundable deposit to secure your child's spot in camp this summer. Deposit amount is $200.00 and can be made by check mailed to Khalsa Camp, 189 Long Plain Rd. Leverett, MA 01054; or you can Venmo your deposit to @siriom-fuller (last 4 digits of phone number are 9388)
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Email *
Camper Name
Camper DOB
MM
/
DD
/
YYYY
Camper preferred pronouns
Parent Name (#1)
Parent phone (#1)
Parent email (#1)
Parent Name (#2)
Parent phone (#2)
Parent email (#2)
Address
Second address (if applicable)
Parent # 1 location during camp hours and directions on how best to contact
Parent # 2 location during camp hours and directions on how best to contact
Sessions
Yes
Forest Friends week 1 (July 1 - 5)
Forest Friends week 2 (July 8 -12)
Nature Challenge week 1 (July 15 - 19)
Nature Challenge week 2 (July 22 - July 26)
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I am sending my $200.00 Deposit in to hold my child's spot: 
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Would you like to add on transportation from Mt. Toby Meetinghouse on our trip days? (This is limited and an additional fee:
Forest Friends $25-35 sliding scale per week
Nature Challenge $40-50 sliding scale per week (In this session we travel more, and to further locations)
You determine what is right for your family to pay.)
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Emergency contact, name and relationship to camper
Emergency contact phone number
Emergency contact #2
Emergency contact #2 phone number
Persons authorized to take child from camp, and phone numbers. (please specify if none)
Photo release:  I give permission for Khalsa Camp and Jai Fuller or Siri Om Fuller to use my child’s photo in promotional materials, including social media, website, and flyers  
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You have the right to request copies of background check, healthcare and discipline policies as well as procedures for filing grievances. Please sign and date
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