Name: Blueberry Season (7/15 - 7/21)
SKU: 532
Availability: InStock

Family Information

The safety and welfare of all members of each family group, (that is, both family and non-family members coming to camp with you) is of our utmost concern. It is with this in mind that we require the following information for all individuals in your family group. It is important to emphasize that the answers to the questions are kept completely confidential, and do not affect whether or not one can participate in camp activities. They are simply used by the camp nurse so we can be prepared.

Because of insurance and accreditation requirements, we need to have assurance that each adult member (18 and over) in each family group approves the terms of our Permission to Provide Medical Treatment, Covid and Activities Waiver. Also, should they provide approval of use of their photo and statements (optional), such approval must also be acknowledged. Adult parents/guardians can acknowledge approval on behalf of their children and/or other minors (i.e. children under 18).

To accomplish approvals electronically, each of the adults must enter their name as an acknowledgement that they have read and approve the terms of camp policy. If each adult is not available to personally enter their name on the form, the person completing the form may enter other adults' names, with their approval, after discussing the purpose and content of the respective statements with them. Entry of names in this way acknowledges that the adult has been made fully aware of the policy, and that they agree to such terms.

Total # of Family Members (Including Yourself)*

Please enter a number from 1 to 10.

Family Representative

For Registration Purposes

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region Country

ZIP / Postal Code

Email*

Enter Email Confirm Email

Phone*

Alternate Phone

Family Names

Family Member Full Name*

(include both family and non-family members)

Age*

(at time of attendance)

Sex*

List Food, Insect Sting, and/or Medication Allergies.

(We recommend campers with Epi-Pens carry them at camp)

Food Allergies

Insect Sting Allergies

Medication Allergies

Vegetarian?*

Date of last tetanus shot*

Last Complete Physical within 12 months?*

Family Member 1

Full name*

Age*

Sex*

M
F

Food Allergies*

Insect Sting Allergies*

Medication Allergies*

Vegetarian*

Y
N

Date of Last Tetanus Shot*

Last Complete Physical within 12 months?*

Y
N

Family Member 2

Full name*

Age*

Sex*

M
F

Food Allergies*

Insect Sting Allergies*

Medication Allergies*

Vegetarian*

Y
N

Date of Last Tetanus Shot*

Last Complete Physical within 12 months?*

Y
N

Family Member 3

Full name*

Age*

Sex*

M
F

Food Allergies*

Insect Sting Allergies*

Medication Allergies*

Vegetarian*

Y
N

Date of Last Tetanus Shot*

Last Complete Physical within 12 months?*

Y
N

Family Member 4

Full name*

Age*

Sex*

M
F

Food Allergies*

Insect Sting Allergies*

Medication Allergies*

Vegetarian*

Y
N

Date of Last Tetanus Shot*

Last Complete Physical within 12 months?*

Y
N

Family Member 5

Full name*

Age*

Sex*

M
F

Food Allergies*

Insect Sting Allergies*

Medication Allergies*

Vegetarian*

Y
N

Date of Last Tetanus Shot*

Last Complete Physical within 12 months?*

Y
N

Family Member 6

Full name*

Age*

Sex*

M
F

Food Allergies*

Insect Sting Allergies*

Medication Allergies*

Vegetarian*

Y
N

Date of Last Tetanus Shot*

Last Complete Physical within 12 months?*

Y
N

Family Member 7

Full name*

Age*

Sex*

M
F

Food Allergies*

Insect Sting Allergies*

Medication Allergies*

Vegetarian*

Y
N

Date of Last Tetanus Shot*

Last Complete Physical within 12 months?*

Y
N

Family Member 8

Full name*

Age*

Sex*

M
F

Food Allergies*

Insect Sting Allergies*

Medication Allergies*

Vegetarian*

Y
N

Date of Last Tetanus Shot*

Last Complete Physical within 12 months?*

Y
N

Family Member 9

Full name*

Age*

Sex*

M
F

Food Allergies*

Insect Sting Allergies*

Medication Allergies*

Vegetarian*

Y
N

Date of Last Tetanus Shot*

Last Complete Physical within 12 months?*

Y
N

Family Member 10

Full name*

Age*

Sex*

M
F

Food Allergies*

Insect Sting Allergies*

Medication Allergies*

Vegetarian*

Y
N

Date of Last Tetanus Shot*

Last Complete Physical within 12 months?*

Y
N

As a parent/guardian of each of the children attending camp with you, can you attest that all immunizations required for school is up to date for each child of school age?*

Yes
No

Please explain.

Has any member of the family had recent or past medical conditions(s) or treatment(s) that could affect participation in physical camp activities?*

Yes
No

Please explain.*

Family Camp Registration

Blueberry Season (7/15 – 7/21)

2021 Summer Registration

Family Information

Family Representative

Family Names

Family Member 1

Family Member 2

Family Member 3

Family Member 4

Family Member 5

Family Member 6

Family Member 7

Family Member 8

Family Member 9

Family Member 10

Emergency Contact Information

Primary Care Physician

Non-Family Member Contact Information

Other Information

Permission to Provide Medical Treatment

Activity Waiver

Consent for use of Family Photos & Statements

Coronavirus / COVID-19 Warning & Waiver

Proof of Vaccination

Payment, Refund & Cancellation Policy

A cash discount of 2.6% will be applied to payments made via check, or money order.  To select this form of payment, choose Pay by Phone. You will be emailed an updated invoice.

Family Camp Registration

Blueberry Season (7/15 – 7/21)

2021 Summer Registration

Family Information

Family Representative

Family Names

Family Member 1

Family Member 2

Family Member 3

Family Member 4

Family Member 5

Family Member 6

Family Member 7

Family Member 8

Family Member 9

Family Member 10

Emergency Contact Information

Primary Care Physician

Non-Family Member Contact Information

Other Information

Permission to Provide Medical Treatment

Activity Waiver

Consent for use of Family Photos & Statements

Coronavirus / COVID-19 Warning & Waiver

Proof of Vaccination

Payment, Refund & Cancellation Policy

A cash discount of 2.6% will be applied to payments made via check, or money order. To select this form of payment, choose Pay by Phone. You will be emailed an updated invoice.

Related products

Blueberry Season 2 (July 19-25)

Raspberry Season (7/1 – 7/7)

Strawberry Season (6/24 – 6/30)

Blueberry Season (7/21 – 7/27)

A cash discount of 2.6% will be applied to payments made via check, or money order.  To select this form of payment, choose Pay by Phone. You will be emailed an updated invoice.