Clone of Summer Camp Detailed Registration Form

Rocky Mount Spring Camp 2026 Registration Form

Welcome to Rocky Mount Spring Break Camp! We’re thrilled you’re joining us for a summer of hands-on history, outdoor exploration, and frontier fun. Please complete the form below to register your child. One form per camper, please. Camp will run for two weeks, March 16th-20th and March 23-24th, Monday through Friday from 9:00am to 3:00pm. Children will need to bring their own lunch daily.
🧒 Camper Information
Camper's Full Name

First NameLast Name
Birth Date

MonthDayYear
Grade Completed
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has your camper attended Rocky Mount before with a school group or previous camp?

YESNO
Camp Session Selection (each week is Monday through Friday from 9am to 3pm). Which week or weeks will your child attend, mark all that applies:

Week 1 (March 16-20)Week 2 (March 23-27)
Will your camper need extended care?

Early drop-off (8:30am)Late pick-up (4:00pm)No extended care
Are any siblings also attending camp? Yes or no, if yes, please list name(s). (Each child must be registered separately)
Parent/Guardian Information
Name

First NameLast Name
Relationship to Camper
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number
Cell Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Does the camper have any allergies, chronic illness, medical conditions, or any other needs we should be aware of? If yes, please describe.
Is the camper prescribed an inhaler or any daily medications at home we need to be aware of? If yes, please describe. (Rocky Mount staff will not be responsible in administering any medication.)
**Rocky Mount Staff do not administer medications of any kind. By selecting below you are giving permission for Rocky Mount staff to help/aid the camper to self administer the following if needed (select all that apply):

Basic first aid (band-aids, ice packs)Sunscreen (provided by the camper)Bug spray (provided by the camper)
Physician's Name and Office Phone Number
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Rocky Mount during the selected camp. In exchange for the acceptance of said child’s candidacy by Rocky Mount., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Rocky Mount State Historic Site and the Rocky Mount Historical Association. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Rocky Mount Historic Site and the Rocky Mount Historical Association, including all staff and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in any outdoor activity. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Medical Release and Authorization

As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named camper. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Rocky Mount Historic Site and Rocky Mount Historical Association, and its affiliates including Directors, Staff, and Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Photo Release

I certify that I am the parent or guardian of the minor camper named in this form and have the authority to grant this release. I hereby grant permission to Rocky Mount State Historic Site and the Rocky Mount Historical Assiciation, their representatives, employees, and agents, to take photopgraphs and or/videos of me and/or my minor child(ren) during this event. I authorize Rocky Mount to use these images in any promtional materials, including but not limited to: the organization's website, social media channels, printed brochures, newsletters, and other marketing or educational publications.

I understand that: these images may be used without notifing me; there will be no compensation for the use of these images; and the rights granted are perpetual and may be used in future promtions without additional permission.

I waive any right to inspect or approve the finished product in which the images appear.
Photo Release

YES I agree to the above termsNO I do not give permission
Camp Rules and Code of Conduct as Frontier Leaders at Rocky Mount

1. Respect each other and the staff at Rocky Mount
1. We show respect to ourselves and others by:
  1. We do not use bad language.
  2. If something does not belong to us; we do not touch it without permission.
  3. We keep our hands, feet, and objects to ourselves. We do not hit, push, tease others in a hurtful way, make threats or act in a threatening way toward others.
2. Listen to and obey the adults in charge of your activities to help keep you safe (for example nature hike, fireside cooking, woodworking...)

3. Stay with the group at all times.

4. Observe the special rules that apply to our behavior while on the historic site (these rules will be discussed during camp).
1. Compass Directions:
1. North (Courage)
2. East (Responsibility)
3. South (Team Spirit)
4. West (Communication)
5. Center (Reflection)
I have read, understood, and agree to the camp rules and code of conduct.

YES
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Rocky Mount Spring Camp 2026 Registration Form

🧒 Camper Information

Photo Release

Camp Rules and Code of Conduct as Frontier Leaders at Rocky Mount