Camp Brosend

Camp Camp Brosend’s Brosend’s 20072013 Day Day Camp Camp Registration FormReturn completed form along with deposit (non-refundable/non-transferable) $15/wkReturn to: Camp Brosend, 7599 Camp Brosend Rd, Newburgh IN 47630 812-853-3466Indicate with a X which weeks to enroll this camper: __1-2 days __ 3 days __4-5 days __M __T __W __R __F__ #1 5/28/13– 5/31/13 (no camp 5/27) __ #4 6/17/13 – 6/21/13 __ #7 7/8/13 – 7/12/13 __ #10 7/29/13 – 8/2/13__ #2 6/3/13 - 6/7/13 __ #5 6/24/13 – 6/28/13 __ #8 7/15/13 – 7/19/13 __ #11 8/5/13 – 8/9/13__ #3 6/10/13 – 6/14/13 __ #6 7/1/13 – 7/5/13 (no camp 7/4) __ #9 7/22/13 – 7/26/13Please type or print the following information:Camper’s Name________________________________________Boy_____Girl_____Age_____Birth Date___________Home Address_______________________________________________________Grade in fall 2013________________City_____________________________State______ZIP_____________Home Phone_____________________________Spring 2013 School_________________________________________School Corporation_________________________Camper’s T-shirt Size (circle one): Youth S Youth M Youth L Adult S Adult MMother’s Name__________________________________Cellular__________________Work Phone________________Father’s Name__________________________________Cellular__________________Work Phone_________________Parents’ Email Address______________________________@_______________________________________________Church Name__________________________________Pastor's Name___________________Church Phone___________Parents who live separately can use this line to provide the information for (circle): Mother FatherAddress_________________________________________________________Preferred Phone__________________The Emergency Contact should be someone other than a parent in case they cannot be reached.Emergency Contact Name______________________________Relationship______________Phone_________________Authorized people to pick up my child (ID required)__________________________________________________________________________________________________________________________________________________________If parents are divorced, who is custodial parent____________________________________________________________Person responsible for payment________________________________________________________________________Payment Information: ____ weeks X $15 deposit per week = $________Cash__ Check #____ Visa__ MC__ Disc__For Credit Card Payments: ____ Deposit Only ____Deposit & Weekly Fee (Monday of each week)__/__ ECf __/__ LCf __sig__ EC __$ __CHCR __ImCard # ______-______-______-______ Exp Date ____/____ Cardholders’ Signature____________________________Further Comments (use extra paper if needed)_______________________________________________________________________________________________________________________________________________________________As the parent or legal guardian of the above child and by signing this form:Please initial each line• I hereby consent for my child to attend and participate in all activities provided by Camp Brosend. ________• I certify the accuracy of all statements and the information provided on this form. ________• I give my permission to provide routine health care, dispense medications, and seek emergency medical treatment for the camper. ________• I understand that I am financially responsible for any expenses incurred through emergency medical treatment given to this camper. ________• I give my permission for my child to be photographed for publicity purposes and optional photo purchasing. ________• I understand that payment is due in full upon drop off on the first visit of each week of camp and that payments made after this time mustinclude a $10 late fee per child. I understand that I am responsible for payment in full for all sessions registered.________• I understand that in order to change, cancel, or alter the number of days in a week for one or more weeks of camp, written notice must besubmitted to the camp office at least 2 weeks prior to the session. If I fail to submit this notice within 2 weeks prior, I understand that I will bebilled for the full program fee for the week.________MUST BE SIGNED BY PARENT OR LEGAL GUARDIANParent/Guardian Signature____________________________Printed Name________________________Date___/___/13Required Health Info on Reverse Side