Waltonian Youth Camp Application printable pdf download

2016

WALTONIAN YOUTH CAMP

APPLICATION

Name

Age

Gender

Address

City

Zip

Phone (home)

Work

E-Mail Address

T-Shirt Size: S_____M_____L_____XL_____XXL_____XXXL_____

MEDICAL INSURANCE COVERAGE PROVIDED WHILE AT CAMP

The Waltonian Youth Camp will be held at Ross Camp in West Lafayette Indiana, July 24

through July 30

, 2016

ALL CAMPERS MUST BE AT LEAST 9 YEARS OF AGE BY SEPTEMBER 1, 2016.

Check In Time:

Sunday, July 24, 2016 1:00 p.m. to 3:00 p.m. CST (Do Not Come Early)

Check Out Time:

Saturday, July 30, 2016 at 10:30 a.m. CST (Do Not Be Late)

Camp Registration Fee: $100.00 per camper (must accompany application)

After July 17, 2016:

$110.00 ----------------- Day camp starts: $125.00

Please Make Check Payable to: I.W.L.A. Youth Camp

Chapter or Person Sponsoring:

Remit to:

IWLA Youth Camp

Name

Stanley M. Jarosz, Jr.

3840 Barnes Street

Chapter________________________________________

Hobart, IN 46342

Cell Phone (219) 730-0496

E-mail address:

• CHILDREN OF IZAAK WALTON MEMBERS ARE GUARANTEED A PLACE ONLY UNTIL JUNE 1

•

• AFTER JUNE 1

, APPLICATIONS FOR NON-MEMBER CHILDREN WILL BE ACCEPTED. •

• PARENTAL PERMISSION •

I hereby give permission for my child/ward _________________________________ to participate in the Waltonian Youth Camp,

planned by the Indiana State Division of the Izaak Walton League of America, Inc. and its chapters.

If for any reason my child/ward should not abide by the camp rules and regulations, I will be contacted and advised of the situation

by the Camp Director. I will then inform the Camp Director or assistant director of my decision of how my child/ward will depart

from camp. I will not hold the Waltonian Youth camp responsible after my child/ward leaves the Tippecanoe State Park

campgrounds.

I understand that due and reasonable precautions will be taken to safeguard my child or ward on this activity as are taken in all other

similar activities. I will not hold the Indiana Division and chapters or any of its employees responsible for any accident or loss that

may occur at camp and while traveling to and from camp. I have read and understand the rules and regulations of the camp and that

my child/ward has been instructed to follow them.

I give my child/ward permission to participate in the Gun Safety and Archery classes during the hands on portion on the ranges.

Archery Yes______ No______

Gun Safety Yes______ No ______

I authorize the IWLA Youth Camp, to use my child/ward’s image and/or voice and/or words in video, photographic, and computer-

generated presentations as part of the promotion of the youth camp.

Yes______ No______

I authorize the printing of my child/ward’s name and address in the camp yearbook.

Yes______ No______

Signature of parent or legal guardian

Date

Waltonian Youth Camp Application

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