Agassiz Village Camper Registration
2014 Camper Registration Form
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  • * All sessions are Two-Week sessions! You may register for up to TWO sessions. Please refer to our program descriptions at
    www.agassizvillage.org for details of each program.

    Please Note: INSTEP Program (ages 16-17) is a four-week, tuition-free program for select candidates. It will require a separate application. Please contact us for more details.
  • CAMPER INFORMATION

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  • If yes, please explain below.
  • Primary Parent / Guardian Information

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  • i.e. mother, father, grandparent, etc.
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  • Emergency Contacts

    Please provide emergency contacts in case the ones above cannot be reached. Emergency contacts must be different from the ones in parent/guardian section.
  • Name
  • i.e. grandparent, aunt, sibling, etc.
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  • Name
  • i.e. grandparent, aunt, sibling, etc.
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  • Family Information

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  • If Yes, you will receive additional information and details in Parent Handbook.
  • If Yes, complete FINANCIAL AID APPLICATION section below!
  • Financial Aid Application

    To be eligible for financial aid rates you must:
    1. Complete this section FULLY.
    2. Submit PROOF OF INCOME (i.e. copy of the first page of your Income Tax Return).

    After we receive this application we will send you the confirmation with apporved rates based on information provided here!
  • Families on Public Assistance (FDPIR, TANF, TAFDC, etc): Please mail a copy of your Benefit Card. We will also mail you an additional form to fill.
  • If YES, there will be a ADDITIONAL APPLICATION AND APPROVAL PROCESS. Please call us for more information and forms.
  • By typing your initials above you confirm that all financial information entered above is correct.
  • Additional Camper Information

  • If yes, when?
  • If yes, please tell us where?
  • If yes, please explain.
  • (e.g. vegetarian, no pork, no peanuts, etc)
  • If yes, please explain.
  • (e.g. dogs, dark, heights, other)
  • (e.g. active, shy, intelligent, etc.)
  • (e.g. hitting, yelling, sulking, crying, running away, etc.)
  • If yes, how recent and how frequent?
  • If yes, when and why?
  • If yes, when and why?
  • If Yes, please provide therapist/counselor name
  • Therapist/Counselor Phone #
  • Terms & Conditions and General Permission Statement:

    • I understand that if my child needs to be sent home due to behavioral or other reasons, I take full responsibility for picking him/her up regardless of the location;

    • I agree to pay the tuition in full (or ensure that my sponsor will pay in full) at least 2 weeks before start of the session(s) my child is attending;

    • I understand that if cancelled less than 2 weeks prior to the start of the session I will forfeit the deposit;

    • I understand that if cancelled within 1 week of the start of the session I will forfeit ALL paid fees;

    • I allow my child to participate in all activities, including trips pre-arranged by camp;

    • I agree to provide a current physical (within last 12 months) and up-to-date immunizations at least 2 weeks prior to the session start;

    • I authorize social service agencies, schools, clinics, doctors, etc to release any information necessary to best plan for my child’s stay at camp;

    • I give permission for Agassiz Village to take, have and use photographs, slides, videos of the applicant for records, promotion materials or public relations;

    • I agree that all information provided in the form is true and hereby release and hold harmless Agassiz Village and its representatives from any claims, causes of
    action, demands, judgments, or costs of any nature whatsoever arising out of applicant’s attendance at camp.

    By choosing "AGREE" below I indicate that I have read this statement and agree to it's terms and conditions: