Springhaven Woods Discovery Camp Registration - 2019
Camper's Name *
Your answer
Birthdate *
Your answer
Sex *
Parent Name *
Your answer
Address *
Your answer
Phone *
Your answer
Work Phone *
Your answer
Email *
Your answer
Number of Sessions *
Acceptable forms of payment include check, cash, or money order. All fees due with registration. Please make checks payable to: Springhaven Woods. Not eligible for State Funded Subsidized Child Care through the Department of Public Welfare.
Required
Camp Session(s) attending *
Please select the sessions which you plan to attend.
Required
Referred by?
Health Information
Emergency Contact *
Name, Relationship, Phone
Your answer
Does your child require any special dietary modifications? *
Your answer
Does your child have any allergies? *
Your answer
Does your child take any medications? *
Your answer
Medical or behavioral conditions:
Your answer
Physician Name
Your answer
Drs Number
Your answer
Insurance Info
Company, Policy Name Holder, Policy Number
Your answer
Pickup *
The following individuals are permitted to pick-up my child from Springhaven Woods Camp. I understand that my child will be permitted to leave with these individuals only. Please list name, relationship, and phone number for all authorized individuals..
Your answer
Agreements
Please check all points if you agree to abide by these camp policies.
Communicable Disease & Lice *
I agree to inform the camp within 24 hours if my child or any member of my household develops a reportable communicable disease or lice.
Medical Treatment *
I hereby authorize Springhaven Woods and/or designated contractor to seek medical treatment for my child, at the nearest facility, in the event medical care is required. In the event non-emergency medical care is required, I authorize Springhaven Woods to seek medical treatment through my child’s physician. I understand that I am responsible for medical expenses incurred by my child and that Springhaven Woods advises I carry health insurance for my child.
Sunscreen *
I give my child permission to apply sunscreen to him/herself and I will be supplying my child with sunscreen.
Pick-up *
The center shall notify parents/guardians whenever the child becomes ill and the parent/ guardian will arrange to have the child picked up as soon as possible.
Photography *
I hereby grant approval for my child to be photographed and/or videotaped by Springhaven Woods to be used for the sole purpose of promoting or publicizing.
Signature *
Please type your name and date below if you agree to the above terms.
Your answer
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