July 3 ~ 9, 2022

Name: July 3 ~ 9, 2022
SKU: 2401
Availability: InStock

Celebrate July 4^th with family and new friends. Red, white and blue crafts abound. The warmer days will make you long for a dip in the lake.

3 in stock

2022 Summer Registration

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)

Gender*

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*
Gender*
- Male
- Female
- Non-Binary
- prefer not to share
Food Allergies*
Insect Sting Allergies*
Medication Allergies*
Vegetarian*
- Y
- N
Date of Last Tetanus Shot*
MM slash DD slash YYYY
Last Complete Physical within 12 months?*
- Y
- N
Family Member 2
Full name*
Age*
Gender*
- Male
- Female
- Non-Binary
- prefer not to share
Food Allergies*
Insect Sting Allergies*
Medication Allergies*
Vegetarian*
- Y
- N
Date of Last Tetanus Shot*
MM slash DD slash YYYY
Last Complete Physical within 12 months?*
- Y
- N
Family Member 3
Full name*
Age*
Gender*
- Male
- Female
- Non-Binary
- prefer not to share
Food Allergies*
Insect Sting Allergies*
Medication Allergies*
Vegetarian*
- Y
- N
Date of Last Tetanus Shot*
MM slash DD slash YYYY
Last Complete Physical within 12 months?*
- Y
- N
Family Member 4
Full name*
Age*
Gender*
- Male
- Female
- Non-Binary
- prefer not to share
Food Allergies*
Insect Sting Allergies*
Medication Allergies*
Vegetarian*
- Y
- N
Date of Last Tetanus Shot*
MM slash DD slash YYYY
Last Complete Physical within 12 months?*
- Y
- N
Family Member 5
Full name*
Age*
Gender*
- Male
- Female
- Non-Binary
- prefer not to share
Food Allergies*
Insect Sting Allergies*
Medication Allergies*
Vegetarian*
- Y
- N
Date of Last Tetanus Shot*
MM slash DD slash YYYY
Last Complete Physical within 12 months?*
- Y
- N
Family Member 6
Full name*
Age*
Gender*
- Male
- Female
- Non-Binary
- prefer not to share
Food Allergies*
Insect Sting Allergies*
Medication Allergies*
Vegetarian*
- Y
- N
Date of Last Tetanus Shot*
MM slash DD slash YYYY
Last Complete Physical within 12 months?*
- Y
- N
Family Member 7
Full name*
Age*
Gender*
- Male
- Female
- Non-Binary
- prefer not to share
Food Allergies*
Insect Sting Allergies*
Medication Allergies*
Vegetarian*
- Y
- N
Date of Last Tetanus Shot*
MM slash DD slash YYYY
Last Complete Physical within 12 months?*
- Y
- N
Family Member 8
Full name*
Age*
Gender*
- Male
- Female
- Non-Binary
- prefer not to share
Food Allergies*
Insect Sting Allergies*
Medication Allergies*
Vegetarian*
- Y
- N
Date of Last Tetanus Shot*
MM slash DD slash YYYY
Last Complete Physical within 12 months?*
- Y
- N
Family Member 9
Full name*
Age*
Gender*
- Male
- Female
- Non-Binary
- prefer not to share
Food Allergies*
Insect Sting Allergies*
Medication Allergies*
Vegetarian*
- Y
- N
Date of Last Tetanus Shot*
MM slash DD slash YYYY
Last Complete Physical within 12 months?*
- Y
- N
Family Member 10
Full name*
Age*
Gender*
- Male
- Female
- Non-Binary
- prefer not to share
Food Allergies*
Insect Sting Allergies*
Medication Allergies*
Vegetarian*
- Y
- N
Date of Last Tetanus Shot*
MM slash DD slash YYYY
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.*

Emergency Contact Information
Name*
First Last
Phone*
Alternate Phone
Relationship to Family*
Primary Care Physician
Name*
First Last
Phone*
Insurance Provider*
Group Number*
Non-Family Member Contact Information
Will you have any non-family members joining you at camp who are under 18 years of age?*
- Yes
- No
PARENT/GUARDIAN OF NON-FAMILY MEMBER UNDER 18 YEARS OF AGE
Name*
First Last
Email*
Enter Email Confirm Email
Phone*
Alternate Phone
Other Information
ARRIVAL AND DEPARTURE
Campers arrive for Sunday lunch and depart Saturday morning after breakfast.
Is anyone in your family celebrating a special occasion (e.g. anniversary, birthday, family reunion) during your week at camp?*
- Yes
- No
Please provide us with details so we can make the occasion really special!
This is our family's ___________ summer at Medomak*
How did you hear about us?
Please provide a description.
Is there any additional information that you think we might want to know to help with your reservations. For example, are you traveling with any other families? Special housing requests?
Permission to Provide Medical Treatment
All organized activities at Medomak Camp are supervised. Once campers are participating in activities, unfortunately there is always the opportunity for injuries. For the typical situation at Family Camp, should any accident with injury to a child occurs, an adult, the child's parent or guardian, will be present to act on behalf of their child(ren) who are injured. It is the parent or guardian who has the authority to make any decision as to type and extent of medical treatment. Medomak Camp staff who are on hand at the time will always seek to assist based on their first-aid training in consultation with parent/guardian. Under any circumstance, when parent(s)/guardian(s) are not immediately available, Medomak Camp staff may need to take immediate action to treat an injured child. Also, should an adult be injured such that they are unable to exercise their authority to make a decision as to type and extent of medical treatment, Medomak Camp staff may need to take immediate action. To allow for immediate treatment should a parent/guardian not be readily available, or should an adult not be able to exercise their authority, Medomak Camp requires that every adult camper give permission for Medomak Camp staff, in consultation with medical personnel, to provide either routine or emergency medical treatment. This waiver also serves to allow Medomak Camp staff in consultation with medical personnel to treat all minor children in a given family unit (family and non-family members) in case their parent/guardian is not available or able to participate in medical decisions.

Acknowledgement of the statement below signifies that each person, adult and child, understands and grants permission for Medomak Camp to provide medical treatment as provided in the statement.

Each of the members of the family unit (family and non-family members) registered hereby give permission to medical personnel to administer medical treatment, including hospitalization; to administer medications; to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for the named person who is attending camp with my family. In the case of minor campers (less than 18 years) this approval applies in the event the parent/guardian cannot be reached in an emergency. In the case of an adult, approval applies if in the opinion of the Medomak Camp Director the injured adult is unable to participate in medical decisions.
Check to signify understanding and agreement with the terms of this form**
By checking this box, you are consenting on behalf of all family members included in the registration.
- I confirm permission to provide medical treatment for family members & non-family members listed above.

Activity Waiver
We all must be fully aware that there are potential risks and dangers inherent in engaging in outdoor recreational activities and in living in an outdoor camp environment. To heighten awareness, upon arrival at camp, each family unit (family and non-family members) must participate in a mandatory safety orientation where camp rules and regulations are discussed. As part of the orientation each family member will have the opportunity to ask questions or seek clarification as to any issues related to being at camp. The majority of the rules are cited in our Campers Handbook. We advise camper families to review the Handbook upon arrival at the family camp. A copy of the Handbook can be found in your cabin. If you would like to obtain a copy of the Handbook prior to coming to camp, you can contact Medomak Camp by email or phone to receive a paper or electronic copy.

Each of the members of the family unit (family and non-family members) as entered in the registration form, acknowledge they acknowledge will take the opportunity once at the camp to read the Camper Handbook, discuss any issues with companions or ask any questions of Medomak Camp staff. Through this means, additional information provided on the Medomak Camp website, and conversations with Medomak Camp staff, entry of each name further signifies that adult family (or non-family) members are making an informed decision regarding attendance at Medomak Camp, and understand and accept all of the terms of attending Medomak Camp. Entry of each name acknowledges further understanding and agreement that all activities undertaken by any family member (or non-family member) is done so “at your/their own risk.” Further, entry of each name acknowledged agreement to release Medomak Camp, its owners, officers, employees, agents, and representatives from any and all claims for loss or damage of property and/or personal injury sustained at Medomak Camp or while engaging in activities associated with Medomak Camp.
Check to signify understanding and agreement with the terms of this form*
By checking this box, you are consenting on behalf of all family members included in the registration.
- I confirm consent and agreement to the activity waiver for family members & non-family members listed above.
Consent for use of Family Photos & Statements
We have found that over the years the photos and comments provided by families who attend Medomak are our best kind of marketing. The impact of families telling other families, or statements made by families that we can use on the Medomak Camp website have proven very powerful in our effort to have Medomak Camp grow and be successful. The following form is completely optional. Should any family or non-family member's name be entered, doing so acknowledges that they are willing to let Medomak Camp use any photos or comments attributable to that member of your family or any non-family member that is attending camp with you during your time at camp. Please do not feel obligated to acknowledge this consent. If you do acknowledge, however, we want to thank you for your consideration.

Each of the members of the family unit (family and non-family members) as listed in the registration form, confirm that photographs/statements of, by, or about their experience at Medomak Family Camp may be used in the public domain in promoting the camp or its related activities.
Check to signify understanding and agreement with the terms of this form*
- I confirm consent to the use of photos and statements for family members & non-family members listed above.
- I DO NOT confirm consent to the use of photos and statements for family members & non-family members listed above.
Coronavirus / COVID-19 Warning & Waiver
COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. COVID-19 can lead to severe illness, personal injury, permanent disability, and death. The COVID-related policies and procedures developed and put forward as part of the process whereby each prospective family camp family unit member registers are designed to the fullest practical extent possible to minimize risk of infection and/or spread of the virus to family campers occupying any part of the Medomak Camp property.

As a registered camper at Medomak Camp, I have thoroughly read Medomak Camp’s COVID policies and procedures. I have exercised the opportunity to ask Medomak Camp representatives all questions that I deem necessary to make an informed decision regarding occupancy at Medomak Camp. By affirming this waiver, I understand and accept, and agree to the best of my ability to observe and adhere to the COVID-related regulations stipulated in the Medomak COVID policies and procedures. Specifically, my endorsement signifies compliance by me and all members of my family unit (family and non-family members) with procedures that relate to:
I agree on behalf of myself as well as any minor (person under 18 years of age) in my custody occupying the Medomak Camp property to release Medomak Camp, its owners, officers, employees, agents, and representatives from any and all claims that relate to any illness due to COVID infection acquired during or as a result of my occupancy on the Medomak property.
Check to signify understanding and agreement with the terms of this form*
By checking this box, you are consenting on behalf of all family members included in the registration.
- I confirm consent and agreement to the Coronavirus waiver for family members & non-family members listed above.
Proof of Vaccination
Check to signify understanding and agreement with the terms of this form*
By checking this box, you are consenting on behalf of all family members included in the registration.
- I acknowledge proof of vaccination may be required for entrance to Medomak, and I will be sure to bring along a copy of COVID vaccine record(s) for all required family members, or submit to Medomak prior to arrival.
I understand that if vaccine isn’t yet available for me or a family member prior to my arrival at camp, I may still register now, and may later cancel my registration and have my tuition creditable to a future stay.
Hidden
COVID vaccination verification
If already vaccinated, please upload a copy of each family member's COVID vaccine record. If vaccine isn't available for a family member yet, please bring copy upon arrival.
Drop files here or

Accepted file types: jpg, pdf, Max. file size: 512 MB, Max. files: 10.

Payment, Refund & Cancellation Policy
By submitting a deposit for the [YEAR] Medomak Family Camp season you agree to the following refund policy:
- A non-refundable deposit must accompany your registration form to reserve your family a cabin.
- A 50% payment is due February 1. The full balance is due by May 1. After May 1, payment in full is due upon registration.
- Cancellations within 14 days of your arrival will result in a full credit applied toward a future stay at Medomak. In the event Medomak must cancel a program, a full refund will be given.
- Sorry but Medomak cannot be responsible for nonrefundable airline tickets or other travel or indirect expenses associated with cancellations.)
- A $25 cancelled check fee will be charged for returned checks.
- Reservations are taken on a first come, first served basis.
- Cabin assignments will be based on availability. We make all attempts to accommodate cabin requests, but final assignments are subject to the program needs of Medomak Camp.
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.
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$0.00

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Total

Ordered December
Ordered January
Ordered February
Ordered March
Ordered April
Ordered May
Ordered June
Ordered July
Ordered August
Ordered October
Ordered November

Pay a 4% deposit per item (100% payable over 5 months)

Pay a 4% deposit per item (100% payable over 4 months)

Pay a 50% deposit per item (100% payable over 3 months)

Pay a 50% deposit per item (100% payable over 2 months)

Pay a 50% deposit per item (100% payable over 1 month)

Pay a 100% deposit per item (100% total payable)

Pay a 4% deposit per item (100% payable over 7 months)

Pay a 4% deposit per item (100% payable over 6 months)

July 3 ~ 9, 2022 quantity

June 26 ~ July 2, 2022

June 26 ~ July 2, 2022 quantity
July 17 ~ 23, 2022

July 17 ~ 23, 2022 quantity
July 24 ~ 30, 2022

July 24 ~ 30, 2022 quantity
August 14 ~ 20, 2022 – Grown-ups week

August 14 ~ 20, 2022 - Grown-ups week quantity

Participate in adult art and science retreats (or let us host yours) at our beautiful, peaceful and accommodating retreat facility just down the road. Learn more. »

Medomak Camp is the first full-season secular family camp to be accredited by the American Camping Association.

Winter (September-May)
12230 Clarksville Pike, Suite C
Clarksville, MD 21029
(301) 854-9100

Summer (June-August)
178 Liberty Rd.
Washington, ME 04574
(207) 845-6001

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Family Camp Registration

July 3 ~ 9, 2022

2022 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

June 26 ~ July 2, 2022

July 17 ~ 23, 2022

July 24 ~ 30, 2022

August 14 ~ 20, 2022 – Grown-ups week

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.