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Creature Camp November 5th
A fun and educational way to spend your school breaks!
The Creature Conservancy
4950 Ann Arbor-Saline Rd.
Ann Arbor, MI 48103
This is for children grades 1-5.
Please use one form per child. Register for as many camps as you like. If space remains available, you may register for additional camp(s) later by using this same form.
Payment in full is required at registration ($65). Refunds will be given in full for cancellations made two weeks prior to camp date.
Please have payment and health insurance information ready before completing this form.
Camper's Name
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First
Last
Birth Date
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MM
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DD
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YYYY
Grade
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Parent's Name
*
First
Last
Address
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Phone
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Alternate Phone
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Email
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Confirm
Emergency and Medical Information
Please list two people to contact in case of an emergency situation:
Emergency Contact Name
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Phone
*
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Emergency Contact Name
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Phone
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Does your child have any allergies, physical limitations, or special needs?
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List any medications your child is taking
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All medications must be brought in their original container
Health Insurance Carrier
*
Group/Policy Number
*
Hospital Preference
*
(ex: U of M; St. Joe's; nearest facility; no preference)
Physician's Name and Phone Number
*
Are camper's immunizations up to date?
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Yes
No
FIRST AID PERMISSION: I hereby give The Creature Conservancy permission to perform basic first aid on my child should the need arise. In case of serious accident or illness, every effort will be made to contact a parent or guardian. In the event that I cannot be reached, I hereby authorize The Creature Conservancy to secure treatment for my child with the appropriate medical personnel or facility.
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Yes
No
Photo Permission
*
Yes
No
The Creature Conservancy staff will be taking photographs of camp activities that may be used in promotional materials. I hereby grant permission for my child's image to be included in camp photographs.
By completing this form you are signing your camper up for the Creature Camp on November 5th from 9am - 4pm (Camp After Hours is not offered for this session).
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Yes
Total
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