2024 Jr. Tracker Registration Form

2025 Jr. Tracker Camp Registration Form
Camp Dates: Select One or Both*

July 28-August 1, 2025, Rain or Shine
Student Name:*

First NameMiddle Name (Optional)Last Name
Student Birth Date:*

MonthDayYear
Grade Starting in Fall 2025:*
Student's Preferred Pronouns*
Epi-Pen Required:*

YesNo
Allergies or Prescribed Medication:*

YesNo
If Yes, Please List Allergies or Prescribed Medication(s):
(If allergies or prescribed medication, please have Authorization for Severe Allergy, Emergency Medical Care or Prescribed Medications form completed by a doctor.)
Special Needs:
(If your child has any special needs, medical conditions, or severe allergies that are not self-managed, and warrant special care or instructions, please email AmethystRetreatCenter@gmail.org at least 2 weeks prior to the camp start date to make proper arrangements with our staff.)
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Mobile Number*
Parent/Guardian Home Number
Emergency Contact Name/Relationship to Child:*
Emergency Contact Phone Number:*
Alternative Transportation (If applicable, please share the driver's name, relationship to the child, and phone number):
Photography Release: I authorize Amethyst Retreat Center and its affiliates to obtain, store and/or use (without payment) any photographs orvideo clips of my child for advertising purposes.*

YesNo
What to Bring
• Bag lunch and drink, labeled with your child’s name
• Registration form, if not previously submitted
• Sun screen and/or tick spray, if desired
• Note book and pen/pencil
• Closed-toe shoes
• Any medications, labeled with your child’s name, along with medication administration form, if applicable
• Water shoes
• Change of clothes that can get dirty, preferably neutral colors
• Towel that can get dirty
• Bandana
• Fixed-blade carving knife (MoraKnif is a good, inexpensive option.)
How did you hear about us?

FriendFacebookCPBJ Summer Camp GuideOther
If "Other" please share with us how you heard about us:
Refund Policy:

Payment in full is required at the time of registration. The course cost includes a non-refundable fee of $50 for participants, up to four weeks prior to the first day of the program. Because of costs associated with staffing, all cancellations after July 1st will result in a loss of the entire amount paid. However, if we are able to fill your child’s spot with another student on the waiting list, Amethyst Retreat Center will refund your tuition, less $50. In the event that Amethyst must cancel the camp(s), whether due to e.g. Covid mandate or any other unforeseen circumstances, you will be refunded the full cost of tuition and any before/after care fees.
Medical Release:

You authorize the diagnosis and treatment by a qualified and licensed medical professional of your child, should a medical emergency occur, which the attending medical professional believes required immediate attention to prevent further endangerment of the minor’s life, physical disfigurement or impairment, or undue pain, suffering or discomfort, if delayed. Permission is granted to the attending physician to proceed with any examination, diagnosis and medical or minor surgical or other treatment. In the event there is a medical emergency, you understand that every attempt will be made by the attending physician to contact you in the most expeditious way possible. The authorization is granted only after a reasonable effort has been made to reach you. This release is authorized for the duration of the camp, of your own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the above-named child, in your absence.
Limitation of Liability:
In choosing to attend, the participant and parent hereby releases, discharges, and holds harmless Amethyst Foundation, Inc., including its directors, officers, agents, and employees, from any and all claims, demands, or causes of action arising from injury, damages, property loss, or other liabilities that may occur during or result from participation in the Camp's activities. Furthermore, Amethyst Foundation, Inc. assumes no responsibility or liability for the safety, health, or well-being of any individual participating in or attending the Retreat's activities. All participation is undertaken at the sole risk and discretion of the participants and their legal guardians.
Confirmation: Your signature below, whether written or electronically typed, is accepted as a binding agreement. You accept that you have read and agree to the above Terms and Conditions of the Jr. Tracker program.
Signature:*

Clear
Today's Date:*

MonthDayYear
Date
Type Name:*

First NameLast Name
Please again list your child's name and any comments/notes you may have:*
Where to Send Hard Copy Forms:

If you prefer not to complete the Registration and Medical forms online, please visit amethystretreatcenter.org/tracker-camps to print a copy and mail to: Natalie Manchorov, 71 Hardot Rd, Dauphin, PA 17018.
Payment in full is due at the time of registration.

Credit card payment is accepted online at AmethystRetreatCenter.org/tickets. Personal checks and money orders can be mailed to Natalie Manchorov, 71 Hardot Road, Dauphin, PA 17018, and made out to Amethyst Foundation.
Need more help?

Please contact us at AmethystRetreatCenter@gmail.com or call Natalie Manchorov, coordinator, at 717.979.4147, with any questions or concerns, and we will be happy to help.
Should be Empty:

2025 Jr. Tracker Camp Registration Form

Refund Policy:

Medical Release:

Confirmation: Your signature below, whether written or electronically typed, is accepted as a binding agreement. You accept that you have read and agree to the above Terms and Conditions of the Jr. Tracker program.

Where to Send Hard Copy Forms:

Payment in full is due at the time of registration.

Need more help?