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2009 - Camp - Workshop - Registration - Form - Rev. 1

This document is a registration form for a 2009 camp workshop. It requests information such as the participant's name, address, emergency contact, and which camp they are registering for along with the camp fees. It also provides information on the different camp schedules, fees, and payment options including paying by check or credit card. By signing the form, the participant acknowledges and consents to the activities and agrees to hold the camp organizers harmless.

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42 views1 page

2009 - Camp - Workshop - Registration - Form - Rev. 1

This document is a registration form for a 2009 camp workshop. It requests information such as the participant's name, address, emergency contact, and which camp they are registering for along with the camp fees. It also provides information on the different camp schedules, fees, and payment options including paying by check or credit card. By signing the form, the participant acknowledges and consents to the activities and agrees to hold the camp organizers harmless.

Uploaded by

api-3699829
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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2009 CAMP WORKSHOP REGISTRATION FORM

Full Name _________________________________________________________________________

Parents’ or Legal Guardian’s First Name(s) _________________________________________________

Mailing Address ______________________________________________________________________

City ____________________________________________________ ST ____ Zip ____________

Home Tel ____________________ Cell ____________________ E-mail _____________________

Emergency Contact __________________________ ___________________ _______________


Name Telephone Relationship

Participant Name Camp Name Age Grade M or F Camp Fee Total

_____________________ _______________ _____ _____ _____ $ _______ $ _______

_____________________ _______________ _____ _____ _____ $ _______ $ _______

_____________________ _______________ _____ _____ _____ $ _______ $ _______

_____________________ _______________ _____ _____ _____ $ _______ $ _______

CAMP SCHEDULE AND FEES


Camp Name Grades Dates Fee
High School Camp 9 thru 12 (Heartland) June 29 thru July 4 $210.00
Jr. High 6 thru 8 (KOHOE) July 7 thru July 11 $90.00
Elementary 2 thru 5 (KOHOE) July 12 thru July 14 $50.00
Bus Transportation – from Tensuke Market ($15.00 fee paid by Chicago Family Church) $ N/C

I will travel to the camp by:  Own Car  Chicago Family Church Bus  Other: _______________

CONSENT AND HOLD HARMLESS


I acknowledge that I am participating in an educational workshop organized by HSA-UWC (Family
Federation) and that this activity is being done with my consent and I am aware of the program and
activities involved. I agree to hold HSA-UWC/Family Federation harmless for the safety and wellbeing of
my participation in this workshop and to indemnify HSA-UWC for any and all claims arising there from.

_______________________________ _______________________________ ______________


Signature Printed Name Date

PAYMENT METHOD

 Check (payable to HSA-UWC, Attn: CYM)  VISA  Master Card  Discover (No other cards)
Note: Add 3% of the Camp Fee to the credit card payment amount to cover the bank processing fee.

Credit Card No.  Expiration Date 


Exact Name on Card ______________________________ Signature ________________________

Billing Address _______________________________________________________________________

City ____________________________________________________ ST ____ Zip ____________

PLEASE SUBMIT THIS COMPLETED FORM WITH YOUR PAYMENT, CODE OF


CONDUCT FORM AND MEDICAL AUTHORIZATION FORM.

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