Rebels of the Moon Camp

Rebels of the Moon Camp (Dates, 7/21-7/25 Ages, 10-12)

Location: The Willowell Land (36 Stoney Meadow Lane, Monkton).
Select your camp!*
Camper’s Name*

First NameLast Name
Age (at time of camp)*
Birth Date*

MonthDayYear
Date
Gender

Parent/Guardian A Name*

First NameLast Name
Email (camp leaders will send communications through email)*
example@example.com
Phone Number*
Please enter a valid phone number.
Parent/Guardian B Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Name (other than parent/guardian)*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to camper*
Second Emergency Contact Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to camper*
Is there any other person authorized to pick up your child from camp? Please note them below.

First NameLast Name
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.

What is the participant excited about in relation to camp?
Are there any concerns/fears on the part of the participant or parent in relation to camp?
Other Comments

Please list allergies, physical limitation(s), and special considerations:
Dietary Restrictions
Medications
Doctor’s Name*

First NameLast Name
Doctor’s Phone Number*
Please enter a valid phone number.
Insurance Carrier*
Policy Number*

MEDICAL WAIVER

By signing your name below and clicking submit, the camper’s parent/legal guardian warrants that the camper is physically fit and able to participate in the camp activities, and consents to any employee, agent, or other personnel affiliated with Willowell to seek medical attention and treatment or other measures deemed necessary or advisable in the discretion or judgment of Willowell personnel for the above-named camper in the event of an accident, sudden illness, or other condition that occurs while the above-named camper is in the care or under the supervision of Willowell. The parent/legal guardian further understands that Willowell will make reasonable efforts to notify the parent/legal guardian or another parent of the camper in the case of an accident, sudden illness or other condition, but authorizes Willowell Personnel to seek such care or treatment, and for any care or treatment to be administered, even in the event that either parent or legal guardian are not contacted prior to the seeking or rendering of such, care, treatment, or other measures.
Medical Waiver Signature*

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Date*

MonthDayYear
Date
LIABILITY WAIVER

By signing your name below and clicking submit, the parent/legal guardian understands that camp takes place in outdoor terrain in rustic conditions, rain or shine, excepting inclement or dangerous weather. This could include potentially hazardous activities, such as hiking, fire building, running, playing with foam swords, cooking over a fire, etc. The parent/legal guardian agrees to hold harmless the Willowell Foundation and all associated personnel, from any claims, damages, losses and/or expenses arising out of participation in camp activities and to assume all liability for any and all personal injury, bodily injury, illness or property damage that occurs as a result of participation in such camp activities. The parent/legal guardian also warrants that participation in this camp is voluntary and that the camper and the parent/legal guardian understand the inherent risks involved in camp activities, and the camper agrees to obey all rules and policies mandated by camp personnel.
Liability Waiver Signature*

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Date*

MonthDayYear
Date
PHOTO WAIVER

By signing your name below and clicking submit, the parent/guardian authorizes The Willowell Foundation, administrator of summer camps, to publish the photographs or video taken of my child(ren), and their first name(s) only, for use in printed publications, e-newsletters, videos, and on authorized websites (Willowell.org and the AmeriCorps website, Willowell facebook and instagram). I acknowledge that since my child(ren)’s participation in media produced by the Willowell Foundation is voluntary, we will receive no financial compensation. I further agree that my child(ren)’s participation in any media produced by the Willowell Foundation indicates no rights of ownership whatsoever to me or my child(ren). I release the Willowell Foundation and their employees/contractors from liabilty for any claims by me or any third party in connection with their participation.
Photo Waiver Signature

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Date

MonthDayYear
Date
If you did not sign the photo waiver, is it okay to share photos of your child in a google drive with other camper parents and Willowell staff only? (We often send out weekly recap photos to parents whose children are in a specified camp).*

YesNo
CAMP CANCELLATION POLICY:

If a cancellation is made 21 days before the start of camp, tuition minus a $50 processing fee will be reimbursed. Cancellation anytime three weeks (21 days) prior to the first day of camp will be non-refundable. Please note: your place in camp is not secured until we receive full payment.

REGISTRATION, PAYMENT AND PAYMENT TIERS: Please read carefully

After hitting submit, your child is registered for camp, whether or not you pay through the payment field below. In the unlikely event that this camp is ovebooked due to a system glitch, you will hear from us within the week. In this situation, you will be reimbursed as soon as possible.

You may pay through PayPal or credit card below. Please note, there is a 2% processing fee for payments made electronically.

We are offering a tiered payment choice: actual cost, scholarship, and pay-it-forward options. Please select the amount which is aligned with your financial capacity.

Pay-It-Forward will help children in need of a scholarship attend camp this summer.

If the scholarship cost option is a barrier, please apply for further scholarships through visiting our website, Willowell.org. We offer generous need-based assistance so everyone can attend.

Your payment options are:
- ACTUAL COST: $350.00
- PAY-IT-FORWARD COST: $400.00
- SCHOLARSHIP COST: $300.00
If, in order to attend camp, your familiy is in need of additional financial assistance, skip the payment field below and proceed by hitting the submit button.

To apply for additional aid, visit Willowell.org.
ENTER IN YOUR TIERED PAYMENT AMOUNT: $350, $400 or $300
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Rebels of the Moon Camp (Dates, 7/21-7/25 Ages, 10-12)