CAMPER REGISTRATION 2024

CAMPER REGISTRATION
WALKER CREEK RANCH - PETALUMA, CA

NOVEMBER 22-24, 2024

Must be 13 years old by 12/30/24 to attend
Camper's Information
Camper’s First & Last Name
First name you want printed on your badge:
Address
City, State, Zip
Birthdate Must be 13 by 12/30/2024

MonthDayYear
Date
Age
Driver Lic #
Home phone
Cell phone
Email address you want your instructions sent to:
example@example.com
School
School Name
School City
Grade
Chorus Affiliation/s
Are you a member of Sweet Adelines International?

YesNo
If yes, list your chorus name:
Please list any groups you may sing with. Ex: school, church, community;
Director’s Name/s
Emergency Contacts
Parent / Guardian Names
Contact #1 Name
Relationship
Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Contact #1 Phone
Contact #1 Secondary Phone
Contact #2 Name
Relationship
Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Contact #2 Phone
Contact #2 Secondary Phone
Medical Information
Insurance Company
Group #
Policy #
Physician Name
Physician Phone #
List All Medical Conditions (including ADD/ADHD)
List all medications (including over the counter drugs)
NOTE: In order for any medication to be dispensed to your minor child we need the following turned in at camper check-in

Medicine contained in original pharmacy prescription bottle displaying child’s nameAny over-the counter medications in their original containersMHC Medication Authorization Form signed by parent
List All Allergies (including food or drug allergies)
For specific meals please check:

Gluten freeVegetarianVeganLactose-freeNut-free
Release of Claims
I acknowledge that I am participating in Sweet Adeline International’s, Region 12, Young Women in Harmony Program’s, Mountain Harmony Camp, further known as (the Event), Nov. 22-24, 2024, at Walker Creek Ranch, Petaluma, CA, on my own accord. I give this acknowledgement freely, and knowingly, and I represent and warrant to you that I am physically and mentally fit, and that as a result, am able to participate, and I do hereby assume responsibility for my own well-being. I am fully aware that possible physical injury might occur to me as a result of my participation, and I agree to assume the full risk, including risk which is not specifically foreseeable, of any injuries, including death, damages, or loss, regardless of severity, which I may sustain as a result of participating in any and all activities connected with or associated with the Event. In consideration of the right to participate in the Event, I hereby waive any and all rights or claims I may have as a result of participation in the Event against Sweet Adelines International and further agree to indemnify, defend, and hold harmless Sweet Adelines International, its directors, officers, employees, members, staff, and all individuals assisting in instructing and conducting these activities, and I hereby fully release and discharge them from any and all claims resulting from injuries, including death, damages, or loss, which may accrue to me or my heirs, arising out of, or in any way connected with my participation in the Event.
RELEASE OF CLAIMS PARTICIPANT / STUDENT SIGNATURE REQUIRED *

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Release of Claims Participant Sign Date*

MonthDayYear
Date
Participant's Birthdate*

MonthDayYear
Date
IF PARTICIPANT IS UNDER AGE 18 YEARS OF AGE PARENT MUST FILL IN AND SIGN BELOW:
I, being the parent of enter child's name hereby give permission for my child to participate in the above Event. I have read, and agree with, all terms of the above Release of Claims.
RELEASE OF CLAIMS - PARENT OF MINOR SIGNATURE REQUIRED

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Release of Claims Parent of Minor Signature Date

MonthDayYear
Date
Print Parent of Minor Name
Photo/Recording Release
I hereby give permission for Sweet Adelines International and any of its affiliated organizations, including, but not limited to its regions and chapters, to use my name and/or photographs/artwork/videotapes/electronic representations and/or sound recordings on an ongoing basis for promotional, news, or public relations purposes in print and/or electronic media. I hereby consent that such photographs/artwork/videotapes/electronic representations and/or sound recordings shall be the property of Sweet Adelines International and any of its affiliated organizations. They shall have the right to duplicate, reproduce, and make other uses of such as they desire, free and clear of any claim whatsoever on my part. All rights to fees, commissions, royalties, or profits received as the results of the distribution, sale, or lease of the recordings in any form, are assigned to Sweet Adelines International, to be used in any manner consistent with the purpose of Sweet Adelines International.
PARTICIPANT / STUDENT SIGNATURE REQUIRED*

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Photo/Recording Release Participant Sign Date*

MonthDayYear
Date
Participant's Birthdate*

MonthDayYear
Date
IF PARTICIPANT IS UNDER AGE 18 YEARS OF AGE PARENT MUST FILL IN AND SIGN BELOW:
I, being the parent of enter child's name hereby give permission for my child to participate in the above Event. I have read, and agree with, all terms of the above Photo / Recording Release.
PHOTO RECORDING RELEASE - PARENT OF MINOR SIGNATURE REQUIRED

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Photo Recording Release - Parent of Minor Signature Date Required

MonthDayYear
Date
Print Parent of Minor Name
Each camper receives a camp T-shirt. Please check your size;
Cotton T-Shirt Size

XLg ChildSm AdultMedium AdultLarge AdultX Large Adult1 X2 X3 X
Housing:
We do our best to keep age levels, schools, and friends housed together, or close by, but there is no guarantee. Remember, this is a great place to make new life-long friends! However, if you have a roommate request we have provided 4 spaces.
1. Enter roommate request name & school
2. Enter roommate request name & school
3. Enter roommate request name & school
4. Enter roommate request name & school
Your registration fee of $130 can be paid on our website. You'll find the PAY NOW button at the bottom of the Camper Registration page. We accept credit and debit cards.

You can also pay by check. Make checks payable to: Pacific Shores Region 12 Mail checks to: Mountain Harmony Camp, c/o Cyndi Sharp, 4125 Modoc Ct., Concord, CA 94521

Scholarship Applications can be submitted on the website. You'll find the SUBMIT SCHOLARSHIP button on the Scholarships page, or you can download the pdf from the Downloads page

For questions contact our Camp Director, Cyndi Sharp 925-639-2963
Should be Empty:

CAMPER REGISTRATION

Camper's Information

School

Chorus Affiliation/s

Emergency Contacts

Medical Information

Release of Claims

Photo/Recording Release

Each camper receives a camp T-shirt. Please check your size;

Housing: