2017 Summer Camp Registration Form

Camper Name:*

First NameLast Name

Preferred name, if any:

Date of Birth:*

MonthDayYear

Gender:*

MaleFemale

Check if true:

Camper is Own Guardian

County:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

T-shirt Size:*

Does the camper use any of the following:*

Please send information for the following programs:

RESPITE Weekends (Aug-May)BOWLING (Mattoon/Charleston)HOLIDAY PARTIES (Halloween/Christmas/Easter)

Primary Parent/Guardian(s) Name(s):

Guardian who will be in custody during the camper's attendence(s)

Relationship:

Email Address:

Primary Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Check if true:

Camper lives here

Primary Home Phone:

Area CodePhone Number

Primary Work Phone:

Area CodePhone Number

Primary Cell Phone:

Area CodePhone Number

Secondary Parent/Guardian(s) Name(s):

Other Guardian not living at same address as primary parent/guardian(s) listed above.

Relationship:

E-mail Address:

Secondary Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Check if true:

Camper lives here

Secondary Home Phone:

Area CodePhone Number

Secondary Work Phone:

Area CodePhone Number

Secondary Cell Phone:

Area CodePhone Number

Group Home Name:

The facility/group that this camper is associated with.

Home Contact:

Group Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Check if true:

Camper lives here

Group Home Phone:

Area CodePhone Number

Fax Number:

Area CodePhone Number

QIPD Name:

QIPD Cell Phone:

Area CodePhone Number

E-mail Address:

Nurse Contact:

Must have knowledge of camper medication.

Nurse Phone:

Area CodePhone Number

Emergency Contact Name:*

Used only if guardian/facility is unavailable. Do Not list name/number of someone already listed above.

Relationship:*

Emergency Contact Phone:*

Area CodePhone Number

Who is responsible for paying the camper fee?*

ParentSelfApplied for ScholarshipOther (specify below)

Sponsoring Organization/Other:

It is the parent's responsibility to make sure that sponsor has made payment for your camper. Please verify at least 1 month in advance of scheduled week.

Sponsor Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Sponsor Contact:

Sponsor Phone:

Area CodePhone Number

Cancellation and Refund Policy:

If a cancellation occurs 60 days prior to the beginning of the camper week, payments will be refunded, MINUS the deposit. After this time, no refund will be given except as listed below:

If cancellation occurs for a physician-documented medical reason all fees, MINUS the deposit will be refunded. Or camper can choose a later week to attend camp if space is available.
If during a session it is advised to send a camper home for medical reasons, the remaining portion of the session will be refunded.
No refunds will be made for late arrivals or early departures.

Camp Weeks: Please mark preferences. (R- Residential) (CC- Camper Care)

	1st Preference	2nd Preference	3rd Preference
Week 1: June 4-9 (40+)
Week 2: June 11-16 (30+)
Week 3: June 18-23 (19-39)
Week 4: June 25-30 (21 & under)
DAY CAMP: July 3-7 (All Ages)
Week 6: July 9-14 (40+)
Week 7: July 16-21 (19+)
Week 8: July 23-28 (All Ages) & 2nd Week Campers
Week 9: July 30-Aug 2 (All Ages) Buddy Camp

Due to the nature of camp, and the need to balance cabins based on campers needs, please choose the type of scheduling.

STANDARD SCHEDULING: Camp will schedule the camper with his/her age group and try to honor preferences.SPECIAL SCHEDULING: Camp will do everything possible to specifically met these requests below.

Date Request:

Indicate Specific Week & Reason

Buddy Request Name:

List no more than 2 buddies.

Buddy Request (check all that apply):

Requests Same WeekRequest Same CabinRequest Same Day Unit

Requests NOT TO BE with this camper:

Camper Name & Reason

Camp Fee Payment Calculation:

	Price
1st Week Residential: (Local $420/Non-Local $605)
2nd Week Residential: (Local $420/Non-Local $605)
Day Camp- July 3-7: ($185)
Camper Care: ($185 x ______) (number weeks)
Buddy Camp: ($320 per camper)
TOTAL PAYMENT DUE: (Must be paid 2 weeks before scheduled camp week.)

Deposit Submitted: (If applied for scholarship, only choose/pay scholarship deposit)

	Deposit
Residential Deposit: ($50 x ______) (number weeks)
Day Camp Deposit: ($25)
Camper Care: ($25 x ______) (number weeks)
Applied for Scholarship Deposit: ($25)
TOTAL DEPOSIT DUE (This amount must be paid with application.)

CAMPER BALANCE (Total Payment minus Total Deposit) DUE 2 WEEKS PRIOR to attending.

EARLY BIRD DISCOUNT (Subtract $25 from camper balance if all paperwork & full payment is received by April 1, 2017.)

How is deposit being paid?*

I have put deposit in the mail (Camper is not registered until Deposit is received.)Paypal or Credit Card/Debit Card OnlineCredit Card by phone

Enter Deposit Amount here if paying online. Leave blank if paying another way.

USDSummer Camp Deposit

Custodial Parent, Guardian or Participant (if own Guardian) Must Sign:
In signing this form, I hereby certify that the above information is correct. I give permission for the participant to attend all camp activities including transportation of this participant in privately owned vehicles or public transportation for approved out-of-camp activities.
I agree to any emergency treatment by physician or hospital in the event I cannot be reached. I understand that all medication brought to camp must be clearly labeled as to content, administration times, and dosage.
I understand and assume all the risks associated with participation in an outdoor camping and aquatics program. I relieve Camp New Hope, Inc. from all claims or causes of action arising from this camper’s participation.
I acknowledge that Camp New Hope, Inc. provides accident insurance for every camper; however, the camper’s own family insurance is primary, and Camp New Hope’s is secondary.
I give permission to use the camper’s name and picture in publicizing the work and program of Camp New Hope, Inc.
I recognize the obligation of the Camp Director, in his/her absolute discretion, to terminate the camper’s stay at any time due behaviors or medical conditions which might jeopardize the camper’s or others’ well being.
I will be financially responsible for any medical treatment that is needed for the participant.
I have read and understand the Camper Code of Conduct.

Parent/Guardian Signature or Camper Signature if own guardian*

Printed Name:*

First NameLast Name

Date*

MonthDayYear

Relationship to Camper:*