Summer Camp 2002 Registration Form

SOLD OUT WAIVER & REGISTRATION FORM SOLD OUT
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 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 2002 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
This year NFNC 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 you would 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 Package

Amt: $_______

Sat 10^th-Sat 24^th
Sliding scale: Before 6/15: $430-$950, until 7/15: $500-$950, then: $575-$950.

Module One*

Amt: $_______

Sat 10^th-Sat 17^st
Sliding scale: Before 6/15: $350-750, 7/15: $400-750, after 7/15: $450-750.
(Departure between 1:00 and 5:00 PM on the 17^th)

Module Two*

Amt: $_______

Sat 17^th-Sat 24^th
Sliding scale: Before 6/15: $350-750, 7/15: $400-750, after 7/15: $450-750.
(Arrival between 1:00 and 5:00 PM on the 17^th)

* Please note that the 2 modules are quite different in nature, with the second one being much "lighter". A lot of strong bonds will likely be created during the first week, so if you are only coming for one week, we strongly recommend that it be 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 10-17:	# ____ @ $150 ea.	= _______
Prices will be prorated if attending single module. (* Below age 3 not included in childcare program.)

SOLD OUT

Total: $________

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

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

Home Tel. (_____) _______________ DoB: ____________

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

_______________________________ DoB: ____________

_______________________________ DoB: ____________ Parent/Guardian
Signature: __________________________ ___________
How did you hear about SC2002? Date
________________________________________________

Please indicate your special dietary restrictions:

No Wheat No Dairy No Egg No Sugar No Honey Raw

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: Picture Name Address Email Phone

For me:
For my children:

There are limited scholarships and work exchange opportunities available for those truly in need. Contact Sherri at wex@nfnc.org for details.