Camp Eco Sports Registration & Waiver Please be sure to include a $65 per day or $250 per week
non-refundable registration deposit check to secure your child's reservation for Camp Eco
Sports.
Please provide the following
information: RESERVATION DATES
CHILD'S NAME:
AGE:
M F GRADE BIRTH DATE:
PARENT'S NAME:
PERMANENT ADDRESS:
HOME PHONE:
OTHER PHONE:
E-MAIL ADDRESS:
DOES YOUR CHILD HAVE ANY ALLERGIES,
HANDICAP, OR SPECIAL NEEDS THAT WE SHOULD BE AWARE OF?
OTHERS AUTHORIZED TO PICK-UP
YOUR CHILD PHONE
SWIMMING ABILITY:
CAN'T SWIM BEGINNER
INTERMEDIATE
ADVANCED
INSURANCE INFORMATION
COMPANY:
POLICY NUMBER:
FAMILY DOCTOR:
PHONE NUMBER:
In the event of an accident or injury I state that
my child (as named above) has active insurance and that the above policy will be primary
insurance coverage for my child's participation in Camp Ecology / Eco
Sports. Secondary insurance by
Camp Ecology / Eco Sports will cover limited medical reimbursement only. The health history and
insurance information given is correct and my child (as named above) has permission to
participate in all Camp Ecology / Eco Sports activities. In the event that I cannot be reached in an
emergency, I give my permission to any licensed physician, surgeon, trained paramedic or
hospital to secure proper treatment, order injection, anesthesia, or surgery for my child.
I hereby release Camp Ecology / Eco Sports, Greg Gissler, his insurance, camp staff, and volunteers
from all personal and/or public liability resulting from my child's participation in
Camp Ecology / Eco Sports.
Please be sure to include a $65 per day or $250 per week
non-refundable registration deposit check to secure your child's reservation for Camp Eco
Sports.