WAIVER & REGISTRATION FORM
PLEASE FILL OUT A SEPARATE COPY OF THIS FORM FOR EACH ADULT ATTENDING.

I understand that Summer Camp will offer a large variety of activities that can be physically, mentally, or emotionally challenging.  The level of my participation in any of the activities is at all times completely my choice.  I may stop or say "no" at any time.  In the event of an emergency I give the Summer Camp 2003 Staff permission to call an ambulance or physician.  I release Summer Camp Staff, NFNC, NCI, and anyone affiliated with the Mountain Grove community from all liability for any injury to me from my participation.  This release also applies to the minors listed below for whom I am responsible.
Camp Fees
This year NCI is offering a sliding scale. The low end of the scale represents our basic cost (without overhead or labor) while the top end represents the price one might expect to pay for a typical event of this nature. Any money received above and beyond our basic cost will go towards a scholarship fund for lower income individuals and the improvement of this and future Summer Camps. We trust that you will pay as high on the scale as you are capable.
Please check the Module days you plan to attend:
Complete PackageAmt: $_______
Sat 9th-Sat 23rd
Sliding scale: Before 6/15: $450-$950,
until 7/15: $525-$950, then: $600-$950.
Module One*Amt: $_______
Sat 9th-Sat 16th
Sliding scale: Before 6/15: $350-$750,
until 7/15: $400-$750, then: $450-$750.
(Departure between 1:00 and 5:00 PM on the 16th)
Module Two*Amt: $_______
Sat 16th-Sat 23rd
Sliding scale: Before 6/15: $350-$750,
until 7/15: $400-$750, then: $450-$750.
(Arrival between 1:00 and 5:00 PM on the 16th)
* Please note that the 2 attendance modules are quite different in nature, with the second one being much "lighter" in content. Since we notice that folks tend to bond deeply during the first week, if you're only able to come for one week, we strongly recommend the first week, especially if this is your first camp.
Cost for Children:
All fees include childcare program.
Children under 3: # ____     (free)*
Children age 3-6: # ____ @  $50 ea. = _______
Children age 7-10: # ____ @ $100 ea. = _______
Children age 11-17: # ____ @ $150 ea. = _______
Prices will be prorated if attending single module.
(* Below age 3 not included in childcare program.)

Total: $________
   Participant's Signature (if at least 18 years old):

___________________________________     __________
Name:                                                                 Date 
________________________________________________
Address:
________________________________________________
City, St, Zip:
________________________________________________

Home Tel. (_____) _______________ DoB: ____________

Email: ____________________________________(optional)
Emergency Contact and phone:
____________________________  (_____) ____________
Minors'  Names:
_______________________________ DoB: ____________

_______________________________ DoB: ____________

_______________________________ DoB: ____________

_______________________________ DoB: ____________
Parent/Guardian
Signature: __________________________      ___________
How did you hear about SC2003?                        Date
________________________________________________
Please indicate your dietary choices:
No Wheat No Dairy No Egg No Peanut Other
 
We create a private contact info sheet that will be sent to each camper. Please check only those items that you DO NOT want to appear on the contact sheet, otherwise your information will be included.
DO NOT include: PictureNameAddressEmailPhone
For myself:
For my children:

Please mail check or money order with Registration form to:
NFNC SUMMER CAMP 2003, P.O. Box 51495, Eugene, OR 97405