CAMP UU – 2006 Summer Camp Registration Form

Unitarian Universalist Fellowship of Winston-Salem 4055 Robinhood Road, Winston-Salem, NC 27106 * 659-0331 Session Dates: July 31-August 4, 2006

Child’s Name:_______________________________________

DOB:____________________

Address:__________________________________________________________________

Grade in school for '06-07 school year:___________________________________

Allergies (food, medical, etc.):__________________________________________

Special Needs:__________________________________________________________

ADDITIONAL CAMPER (include the same information as above):

*

*

*

Parent/Guardian Name______________________________

Daytime Phone:________________

Address if different from child:__________________________________________

Emergency contact name and number:________________________________________

I hereby give my consent and authority for the camp counselors, director, or adult participants to take any reasonable action to help assure the safety, health and welfare of my children or youth. I also give consent for any necessary medical treatment, including emergency surgical care as recommended by a licensed physician at an area hospital. In case of emergency please contact me at the above listed number. If I am unable to be reached please call the alternate emergency number. My children are permitted to travel by automobile with adult CAMP UU chaperones in order to participate in camp programming. Drivers may include camp counselors, the director, workshop presenters, and their spouses as well as friends and members of UUFWS. I understand that my child will not participate in such a field trip without prior notice to me as the parent.

My child is covered by the following medical insurance:

Insurance Company:________________________________

Policy #:____________________

Signature of Parent or Legal Guardian:________________________________

Date:_________________________

FEES:

_________Camper at $110.00 = ___________

_________Additional Campers at $90.00 = __________

_________Campers for Before/After Camp Care at $20.00 per camper ___________

Total Camper Fees = ___________

Parent volunteer for 3 days = 1 registration fee ___________

Parent volunteer for 1 day = $30.00 discount ___________

Jr. CIT Discount = $30 ___________

Subtract Discounts from Camper fees = Total REG. Cost ___________

DEPOSIT: A deposit of $30.00 per camper is needed to secure a space for each camper. Registration and deposit due by May 31st.

_________Campers X $30.00 = Day Camp Deposit ______________

Subtract the Deposits from the Total Registration Costs to obtain the final balance of camp fees, due by July 1st.

BALANCE Due for Day Camp = _______________