Registration Form

Personal Information
First Name:
Last Name:
Street Address:
Street Address (cont.)
City:
State: Zip Code:
Day Phone: Evening Phone:
Email:
Age:
HS Graduation Year:

Position:  Shirt Size: 

Date of last tetanus shot:   Current Medications:

Current Medical Conditions:

Insurance Company:   Policy Number:

 

CAMP DEPOSIT AMOUNTS

2009 Summer Fundamental Camp (Day and Resident) (Option 1) - $250
2009 Summer High School Camp (Option 2) - $300
All other camps - $100

 

Roommate Preference Selection-

Complete the following only if you are enrolled in the 2009 Summer Fundamental Resident Camp or the 2009 High School Summer Camp.  Please list desired roommates first and last names.  All attempts will be made to honor your request.

1st Choice:

2nd Choice:

3rd Choice:


I hereby authorize the staff of North Country Camps, Inc. to act for me according to their best judgment in any emergency requiring medial attention and I hereby waive and release the Camp and the University of Minnesota from any and/or all liability for any injuries or illnesses incurred while at Camp or in transportation to a medical facility, except for injury resulting directly from gross negligence or willful misconduct.  I have no knowledge of any physical impairment that would be affect by the above named camper's participation in the Camp program as outlined in the brochure.  I also understand the Camp retains the right to use for publicity and advertising purposes photographs of campers taken at the Camp.

 

______________________________________________
Parent's or Guardian's Signature

 

MEDICAL INFORMATION AND RELEASE OF LIABILITY

Event ___________________________________________________________________________________________

Organization Conducting Event________________________________________________________________________

Participant’s Name _________________________________________________________________________________ (please print)

Address _________________________________________________________________________________________
                (street)                                                                                                                   (city)                           (state, zip)

Contact person in case of emergency:

Name _______________________________ Relation ___________________________

Phone _______________________________

Medical conditions, impairments and allergies of which the staff of the Organization and/or University of Minnesota should be aware:

__________________________________________________________________________________________________

__________________________________________________________________________________________________
(Insert "none" if none)

* * * * * * * *

I understand and agree that some activities occurring as a part of or incidental to the Event may be of a hazardous nature and/or include physical and/or strenuous activity. Understanding this, I state that I have no medical condition or impairment, including the use of medication that might inhibit my active participation in the Event named above.  In the case of an injury or medical emergency, I authorize the staff or employees of Organization and/or the University of Minnesota to render first aid and/or obtain whatever medical treatment he/she deems necessary for my welfare.   I further understand and agree that I will be financially responsible for all charges and fees incurred in the rendering of said treatment regardless of whether my medical insurance would cover such charges and fees.

I have read and understand agree to the terms and conditions of this

release.

Print Name ____________________________________________

Signature ______________________________________________ Date __________________

(If participant is under the age of 18, Parent/Legal Guardian’s signature)

I am the parent or legal guardian of the minor _________________________________________ and am signing this release on behalf of the minor. (Print child’s name)

 

Please print this form and mail it to the address below with your deposit to.
North Country Camps
P.O. Box 18144
Minneapolis, MN 55418

612-270-2534