Please complete each section as indicated. No
camper will be registered untill all information requested in the
application is received.
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 CONTACT: |
Information
for the person responsible for this application (Mother or Father
of camper):
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Name*
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email* |
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Registration Information
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SESSION:
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-*Select your camp
Dates and Fees
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SPECIAL CLUBS:
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Special
Clubs are optional
programs,
extra fees apply. Campers
can sign up for ONE special club per week at camp.
-Spring BASE
-Summer 1 (1st Week)
-Summer 1 (2nd Week)
-Summer 2 (1st Week)
-Summer 2 (2nd Week)
-Summer 3
-Summer 4
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SPECIAL
TRIPS:
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Special
Trips are optional programs, extra
fees apply. Campers can sign up for ONE special trip per
camp session.
-Summer 1
-Summer 2
-Summer 3
-Summer 4
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CAMPER BANK:
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In order to establish a personal
bank account for your camper, please inform
us the amount of the deposit you want to make.
As a guideline only, we reccomend placing $25.00 (US dollars) per
week in your camper's account. This amount is calculated for snacks
only. You can also place additional funds for clothing and souvenirs,
since the recommended amount is not usually sufficient.
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CAMP
PHOTOS CD:
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PHOTOS CD (Pre-Sale)
At the end of camp we offer a Photo CD with hundreds
of camp images. It costs US$ 20.00, but you can pay it with your
camp fees. That way you will save and make sure you get one.
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Camper's Information
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| PERSONAL
INFORMATION : |
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Name |
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Last Name |
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Nickname |
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Number of years Camper has attended
VV
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Camper's Birthday
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Age at Camp
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Gender
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Male
Female
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Camper email |
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School
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CAMPER'S
ADDRESS :
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Home Street Address |
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Zip Code / Other Address Info |
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City / Province / State / Country
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Home Phone (include Area Code) |
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Camper lives at home with:
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Both
Mother
Father
Other
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MOTHER'S
INFORMATION :
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Name |
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Occupation |
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Cell / Phone / Pager |
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email |
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| FATHER'S
INFORMATION : |
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Name
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Occupation |
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Cell / Phone /
Pager |
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email |
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Health Information
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The following information is gathered to assist us in identifying
appropriate care.
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ALLERGIES:
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(Foods, Drugs, Other) Please elaborate in detail |
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SPECIAL
CONDITIONS/CONCERNS:
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Special Medical Conditions
(Asthma, Diabetes, Epilepsy,
Migraine
Headaches,Infections,
Recent Operations or Illnesses)
Please elaborate in detail:
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Otros
Health Problems / Concerns
(Sleeping, Diet, Conduct, ODD, Illnesses, Other)
Please elaborate in detail : |
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MEDICATIONS:
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Please list ALL medications being sent to camp, and read our Medications
Policies
You MUST include
(for each Medication):
(A) Medication Name
(B) Dosage
(C) Administration Times and
(D) Reason for Taking
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ADDITIONAL
INFORMATION
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*
Are there any other medical problems about
which Camp Valle Verde should be made aware?
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Yes
No
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*Does
your camper take any other
medications that will not be sent to camp? |
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Yes
No
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Additional
Notes: : |
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About
Health
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EMERGENCY
CONTACT :
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(in case we cannot contact parents)
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Name / Relationship |
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Cell / Phone / Pager |
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Additional Information
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CABIN
MATES:
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(1)
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(2) |
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First
year campers are given preference for cabin mates.
Please list a maximum of two persons,
who are the camper's age (within 12 months of each other). |
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| VALLE
VERDE SURVEY: |
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How did your
family first learn about
Camp Valle Verde? |
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Please elaborate :
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The Camp Session that
I have chosen for my family is based primarily on: |
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Please elaborate : |
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| SUGGESTIONS/COMMENTS: |
for
our Services and Information : |
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| RECOMMENDATION: |
Please
give us the information of two relatives or friends that could be
interested in Valle Verde: |
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Name: |
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E.mail
(or phone): |
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Name: |
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E.mail
(or phone): |
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The application will not be valid unless all information
requested is received
This application can only be submitted by
the camper's parent or Guardian.
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- To the best of my knowledge, this camper does not have a communicable
disease, and is physically able to participate in all Camp activities
except as indicated above.
- All medical problems or conditions requiring ongoing medical
supervision or care have been fully noted.
- I give permission for this health information to be shared with
the appropriate Camp staff and outside Medical Personnel as necessary.
- I understand that I will be notified if extended care is provided
by the Camp Health Center, or following assessment or treatment
by a local physician.
- In case of emergency, if I cannot be reached, permission is hereby
given to the Camp staff to take whatever steps deemed necessary
to ensure the safety and health of my camper.
- I agree to notify the Camp in writing if any changes occur in
my camper's health status, medications, or family status between
now and the start of the Camp session.
MY NAME BELOW INDICATES THAT ALL
INFORMATION ON THIS APPLICATION FORM IS COMPLETE AND ACCURATE.
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Name* (Parent or Guardian) |
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I,
THE PARENT OR LEGAL GUARDIAN OF THE ABOVE NAMED CHILD, HAVE READ
CAMP VALLE VERDE'S
POLICIES AND PARTICIPATION CONTRACT AND AGREE TO ALL TERMS. |
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