Camp Registration

Camper name

Camper age

Camper date of birth

Week

Parent / Guardian name

Phone

Email

Address

City

State

Zip

Shirt size

Contact 1 full name

Contact 1 phone number

Contact 1 relationship to camper

Contact 2 full name

Contact 2 phone number

Contact 2 relationship to camper

Who will pick up the camper?

List any allergies (optional)

List any medications needed during camp (optional)

Does your child have asthma?

Does your child have diabetes?

Should reapplication of sunscreen or bug spray be needed during camp, do you give permission to camp staff to reapply camp issued sunscreen and/or bug spray?

Does your child require a Epinepherine Auto-Injector to be carried on their person or kept on site? (Optional)

Physician's name (Optional)

Physician's phone (Optional)

In the event of an accident or if your child becomes ill, we will notify who has been listed on the emergency form. If we are unable to contact anyone and we feel that your child needs medical care, do you give us permission to seek medical help?

I hereby grant to Corn Cob Acres, its representatives, and employees the right to take photographs/ videos (through all means including the use of drones) of my child in connection with my child's participation in the activities. I hereby authorize Corn Cob Acres to copyright, use, and publish the same in print and/or electronically. I hereby agree that Corn Cob Acres may use such photographs of my child for any lawful purpose, including but not limited to publicity, illustration, advertising, and Web content.

Summer Camp Registration

Emergency Contact

Contact 1

Contact 2

Additional Information