Earth Camp 2010

August 2 – August 6

Morning Session: 8:00 – 12:00

Afternoon Session 12:00 – 4:00

Half days $15.00 for the week ( $10.00 early bird)

Full Days $30.00 For the week ( $25.00 early bird)

Early Bird Registration before July 20 – scholarships available

Your E-Mail Address (Required)

First Child's name (Required)

First Child's Age (Required)

First Child's Session (Required)

Second Child's name

Second Child's Age

Second Child's Session

Third Child's name

Third Child's Age

Third Child's Session

Parent/Guardian Name(s) (Required)

Address (Required)

Daytime Phone

Evening Phone

Your Name (Required)

Affirmation (Required)

I am the parent or legal guardian of the above named child(ren) and I am informed of the activities offered by the Unitarian Universalist Congregation of the Grand Valley at its Earth Camp. As the parent or legal guardian of my child, I hereby consent for my child to attend and participate in these activities.

Exclusions

My child is to be excluded from the following activities:

I have indicated below any medical/personal information regarding my child which the UUCGV should be aware of. In case of an emergency I grant permission for emergency procedures or hospitalization to be provided for my child. I represent that my consent to and agreement to pay for medical, dental, or hospital care or treatment to be rendered to my child is legally sufficient and that consent from no other person is required by law.

Medical/Personal Information

Emergency Contact (Required)

Emergency Contact Relationship

Emergency Contact Phone (Required)

Emergency Contact Home Phone

Medical Insurance Company

Medical Insurance Group #

Medical Insurance Policy #

Known allergies to food or drugs

Known medical problems or conditions

Name of person(s) allowed to pick up my child (Required)

Name of person(s) NOT allowed to pick up my child

Any other helpful information

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Personal tools

Earth Camp 2010

Medical/Personal Information

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