Summer Camp 2001 Registration Form

REGISTRATION FORM
August 14-26, 2001

Below is the actual registration form directly extracted from the Registration Packet.
Please fill it out and return to the address at the bottom. Make copies as needed.

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

I understand that Summer Camp will offer a large variety of activities that can be physically, mentally, or emotionally engaging. 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 2001 Staff permission to call an ambulance or physician. I release Summer Camp Staff, NFNC, 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
Please check the Module you plan to attend:

Complete Package
Tue 14^th-Sun 26^th
Before 6/15: $400. until 7/15: $475. then: $550.

- - OR - -

Modules:

Module One
Tue 14^th-Tue 21^st
Before 6/15: $350, 7/15: $400, after 7/15: $450.
(Departing time between 1:00 and 5:00 pm on the 21^st.)

Module Two
Sun 19^th-Sun 26^th
Before 6/15: $350, 7/15: $400, after 7/15: $450.
(Arriving time between 1:00 and 5:00 pm on the 19^th.)

*Cost for Children:* All fees include childcare program.
Children 3-6 yrs.:	# ____ @ $25 ea.	= ______
Children 7-10 yrs.:	# ____ @ $100 ea.	= ______
Children over 10:	# ____ @ $150 ea.	= ______
If attending less than full camp, child prices will be prorated. (Children below the age of 3 are free - but are not included in the childcare program.)

Total: $________

(There is limited work exchange available for those in true need. You may contact Karen Lefer at kerenlefer@hotmail.com or at 503-231-4024 for details.)

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

___________________________________ __________
Name: Date
________________________________________________
Address:
________________________________________________
Cty, St, Zp:
________________________________________________

Home Tel. (_____) - ______________________________

Email: __________________________________________
Emergency Contact and phone:

___________________________ (_____) ____________
Minors' Names:
_______________________________ DoB: ___________

_______________________________ ___________

_______________________________          ___________
Parent/Guardian
Signature: _________________________      ___________
How did you hear about SC2001?                           Date
________________________________________________

We create a phone contact sheet that will be sent to every camper. Please check those items that you DO NOT want to appear on the contact sheet, otherwise your information will be on the contact sheet.

DO NOT include: Picture Name Address Email Phone

For me:
For my Children:

Please Mail Check with this Registration Form to:
SC2001, PO Box 214102
Sacramento, CA 95821

A confirmation packet, including contact information, emergency phone numbers, receipt, map with directions, and any last minute news will be mailed to all registrants on or before the 1^st of August. Limited shuttle service is available from Grants Pass and will be arranged by Sharon (email: Sharebyrd1@aol.com). Campers can obtain Medford airport to Grants Pass shuttle information at 541-479-3217. (They require 25 hour advance notice so don't wait until the last minute.) Confirmation packet is not necessary for admission.