Winter Camp Ecology Registration & Waiver
Please be sure to include a $40 per day non-refundable
registration deposit check to secure your child's reservation for Winter
Camp Ecology. Please provide the following
information:
RESERVATION DATES
Additional 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 OR SPECIAL NEEDS THAT WE SHOULD BE AWARE OF?
OTHERS AUTHORIZED TO PICK-UP
YOUR CHILD PHONE
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. Secondary insurance by
Camp Ecology 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 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, Greg Gissler, his insurance, camp staff, and volunteers
from all personal and/or public liability resulting from my child's participation in Camp
Ecology.
Winter Camp Ecology Registration & Waiver
Please be sure to include a $40 per day non-refundable
registration deposit check to secure your child's reservation for Winter
Camp Ecology.