Fillable Camp Registration Form - 2016 printable pdf download

2016 Camp Registration Form

Online registration available at

or mail this form along with payment to Girl Scouts of the Colonial Coast, 912 Cedar Rd, Chesapeake, VA 23322.

Camper’s Name _____________________________________________________________

Parent/Guardian’s Email ______________________________________________________

name and date of the session. Minimum $25 non-refundable deposit required for

each camp/session including sessions attended with

Financial

Assistance. Financial

Address ___________________________________________________________________

Assistance is available for one week per summer.

City ____________________________________ State __________ Zip ________________

Age on June 1, 2016 ________ Birthdate __________________ Grade in Fall 2016 _______

Name of Session

Date of Session

School Name _______________________________________________________________

Mother/Guardian Name ___________________________ Cell Phone __________________

Employer ________________________________ Day Phone ________________________

Father/Guardian Name ___________________________ Cell Phone ___________________

Employer _________________________________ Day Phone _______________________

Custodial Information:  Both Parents

 Mother Only

 Father Only

 Other

Does your camper have any special needs (including dietary)?  Yes

 No

If yes, please describe. _______________________________________________________

Please describe her swimming ability ____________________________________________

While at camp, place my daughter with her buddy: __________________________________

Please indicate camper’s t-shirt size. Available in Youth S—L and Adult S—XL.

 Youth _______

 Adult _______

Payment Information

Parent/Guardian Agreement and Health Statement

Total camp registration fees = $ _____

 Cash

 Money Order

- $15 Early Bird discount (pre-April 1) = $ _____

 Check

I give my camper permission to attend camp and participate in all activities,

I agree my checking account will be debited

$15 Membership fee (if not member) = $ _____

including field trips and swimming/boating where available, unless otherwise

electronically for the face amount, return check

stated on her Medical History. Camp personnel are authorized to give

Donation amount = $ _____

fee & return deposit item fee if returned unpaid.

immediate first aid and/or medical treatment from a licensed physician in

Total due + $ _____

Credit Card:  Visa  MasterCard  Discover

case of accident, injury or illness. Parent/Guardian will be notified of illness

Amount enclosed = $ _____

Amount to be charged $ __________________

and may be required to pick up child from camp. I will not send my camper

Balance due* = $ _____

Account # _____________________________

to camp if she is not well. I give my camper permission to be a Girl Scout

Expiration date _________________________

Will you be using cookie credits?  Yes  No

member if she is not already a member.

Print name as it appears on card:

If yes, how much? $ _____

I have read and understand the refund policy.

______________________________________

*Balance due no later than 30 days prior to camp

Authorized Signature:

session beginning.

I would like to receive camp confirmation via:

 Email  Mail

______________________________________

 Check here if applying for Financial

Parent/Guardian signature ___________________________ Date ______________

Assistance (attach application)

Camp Registration Form - 2016

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