Camp Registration Form printable pdf download

CAMP REGISTRATION FORM

Sec on A - Must be completed for all par cipants (Please print clearly)



Par cipant Name: ____________________________________________ Date of Birth: ___________ Age: _____

M /



Parent/Legal Guardian: ________________________________________________

M /

F Date of Birth: ___________

Address: _________________________________________ City: ____________________ State: _____ Zip: __________

Primary Phone: ____________________________________ Secondary Phone: __________________________________



Email (Parent): ________________________________________________________ Henrico resident?

Y /

Emergency Contact Name: (Spouse, Rela ve, Friend) ______________________________________________________________

Rela onship: ______________________ Primary Phone: _____________________ Secondary Phone: _____________________

Special Accommoda ons & Medica on: If the par cipant requires one (or both) of the following, you must check the box(es)

and call Therapeu c Recrea on at 501-5135. See website for forms and addi onal informa on. (Paperwork is due May 15.)

 Special accommoda ons due to a disability. /  Rescue Medica on(s) needed during program hours.



Photographs: If you do not want pictures of your child taken (for publicity or departmental use), please check here.

Assump on of Liability:

I understand that this program may involve strenuous physical ac vity and that risk of physical injury is inherent in this recre-

a onal ac vity. In considera on for par cipa ng in this program and recrea onal ac vity, I agree to assume the full risk of any injuries, including death, dam-

age, or loss. I further understand that Henrico County, its oﬃ cers, agents, and employees are not liable for any injuries that may result from the negligence of

persons conduc ng this recrea onal program. I understand that this agreement cons tutes an assump on of risk and release for any injury, including death,

damages, or loss. The terms hereof shall serve as a release and assump on of risk for my heirs, executors and administrators. Henrico County recommends

that par cipants secure adequate medical insurance to cover any injuries that may arise from their ac vi es. I have read this agreement and agree to the

condi ons stated above. If par cipant is under 18 years of age, parent or legal guardian must sign this release.

______________________________________________

_____________

Signature of Parent/Legal Guardian (Required):

Date:

Sec on B - PAID CAMPS

Camp Program #

Camp Title

Loca on

Fee

Total Fees: $



Shirt Size:



Payer Name: _________________________________________________________________________________

M /

Address: _________________________________________ City: ____________________ State: _____ Zip: __________

Primary Phone: ____________________________________ Secondary Phone: __________________________________

Method of Payment: Payable to County of Henrico

 Cash (Walk-in registra on only.)  

 Debit Card (Pin-based only. Walk-in registra on only.)

 Credit Card (American Express, Discover, MasterCard, or Visa. Walk-in and online registra on only.)

 Check/Money Order #____________ (Registra on forms sent by mail must be paid by check or money order.)

Sec on C - SUMMER BLAST CAMP & TEEN SCENE CAMP

Summer Blast/Teen Scene Camp Loca on: ___________________________________________________________________

Check which session(s) your child would like to a end:

 I: Jun 27-30  II: Jul 5-7  III: Jul 11-14  IV: Jul 18-21  V: Jul 25-28  VI: Aug 1-4  VII: Aug 8-11

Grade completed during the 2015-16 school year: _______ School: _______________________________________________

In addi on to the parents/guardians, the following designees have permission to sign my child in/out of the program:

Name: ____________________________________________ Contact Number: _____________________________

Mailing Address: Program Registra on, Henrico Recrea on and Parks, PO Box 90775, Henrico VA 23273-0775

Camp Registration Form

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