NHC REGISTRATION

REGISTRATION

Camp New Horizons Aug. 9-14
CAMPER INFORMATION
Name*

First NameLast Name
Birthdate*

MonthDayYear
Gender Identity*
Camper Guardian*

SelfSomeone Else
Guardian Name

First NameLast Name
CONTACT INFORMATION

The email listed below will receive a confirmation message that contains important paperwork and information regarding your camp session.
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code

EMERGENCY CONTACTS

Please include at least one contact other than the listed camper and/or guardian.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relation to Camper*
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relation to Camper

TRANSPORTATION CONTACT

Who arranges the camper's transportation? If self, please fill in your information again.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

MEDICAL CONTACTS
Physician*

First NameLast Name
Hospital / Clinic*
Email
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Mental Health Provider / Counselor

First NameLast Name
Hospital / Clinic
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

ADDITIONAL DETAILS
The camper...*

is new to New Horizons Camphas attended New Horizons Camp before
Shirt Size*
Cabin-Mate Request
We cannot guarantee these requests.
Dietary Needs or Restrictions
Please be aware that our food may contain or come into contact with common allergens, such as dairy, eggs, wheat, soybeans, tree nuts, peanuts, fish, shellfish or wheat. While we take steps to minimize risk and safely handle the foods that contain potential allergens, please be advised that cross contamination may occur, as factors beyond our reasonable control may alter the formulations of the food we serve, or manufacturers may change their formulations without our knowledge.

CAMPER INTAKE QUESTIONNAIRE
Please tell us a bit about the camper's needs, challenges, and/or diagnoses:*
Does the camper have any fears or anxieties? If so, what are they?*
Does the camper have any calming or comforting techniques? If so, what are they?*
What are some of the camper's interests?*
Favorite hobbies, activities, shows, music, foods, etc.
Can the camper comfortably walk up to 3 miles per day on average?*

YesNo
Please describe any mobility concerns the camper may have.
During this session, campers can expect to walk up to 3 miles per day, including stairs, inclines, gravel pathways and some areas with uneven ground. While we are working diligently on a solution, we do not have the vehicles required to transport campers around the site at this time.
How would you describe the level of assistance needed by the camper for tasks such as dressing, eating, bathing, or toileting?*

NoneMinimalModerateHigh
Please describe any type of assistance that may be needed.
Your response helps us provide the best experience possible for your camper.
Additional comments and/or notes.

PERMISSIONS
Camp Burton has permission to video/photograph the camper for...

promotional usethe digital photo album
Signature*
Date*

MonthDayYear
Date

PAYMENT
Select what you would like to pay today (includes 4% processing fee):*

Non-Refundable Deposit ($52.00)Full Tuition Cost ($520)I'd like to contribute to the campership fund.
Payment Selection
Please select a method for paying the remaining amount due.

I will pay by mail or in-person using check, cash, or cardI would like DSHS/DDA to be billed for the remaining feesI would like to request a campership
Paying By Mail or In-Person

Camp Burton will send an invoice to the main contact email listed on or around June 15. This invoice will document today's payment and show the remaining tuition balance due on or before the first day of your camp session.
DSHS/DDA Contact
Name

First NameLast Name
Email
example@example.com
Campership Request

It is part of our mission to make summer camp accessible to all regardless of a camper’s financial situation. We encourage you to request assistance if you need it. Financial aid typically goes to those who have many dependents or are facing financial hardship. This process is honor-based and confidential. Our funds are limited, we might not be able to grant every financial aid request.
How much can be paid towards the remaining tuition amount?
Minimum: $50 non-refundable deposit
Does the camper/family receive any other benefits (SNAP, DSHS, etc.)?

YesNo
Please provide us with any other information you think we should know.
Today's Total*

prevnext( X )
USDDescription
Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info
Should be Empty:

REGISTRATION

CAMPER INFORMATION

CONTACT INFORMATION

EMERGENCY CONTACTS

TRANSPORTATION CONTACT

MEDICAL CONTACTS

ADDITIONAL DETAILS

CAMPER INTAKE QUESTIONNAIRE

PERMISSIONS

PAYMENT

Paying By Mail or In-Person

DSHS/DDA Contact

Campership Request