EmailMe Form - Zoo Camp (Grades 4-6) Aug. 27

Camper's Name *

First Last

Birth Date *

MM / DD / YYYY

Grade (Fall 2018) *

This is the grade your child will be entering this fall.

Parent's Name *

First Last

Address *

Street Address City State / Province / Region Postal / Zip Code

Phone *

### - ### - ####

Confirm

### - ### - ####

Alternate phone, if any

### - ### - ####

Confirm

### - ### - ####

Email *

Confirm

ONLY if different from parent listed above, please enter name and email of person who should receive camp information from the Camp Director the week before camp begins. This would normally be the person dropping off the child each day.

Name of person to receive camp information

First Last

Email

Confirm

Options include Camp After Hours for the week ($75) and Night Crawlers on Thursday evening ($25, or $15 if enrolled in Camp After Hours).

Choose "yes" or "no" for Camp After Hours and then you'll see the Night Crawlers options.

Camp After Hours (4:00 - 6:00pm daily) *

Yes, please enroll my child in Camp After Hours. ($75)

No, my child will be picked up at 4pm each day.

Night Crawlers, Thursday 4:00 - 10:00pm *

Yes, please enroll my child in the Thursday evening option. ($25 )

Not at this time - I'll decide when camp starts.

Night Crawlers, Thursday 4:00 - 10:00pm *

Yes, please enroll my child in the Thursday evening option. ($15 if enrolled in Camp After Hours)

Not at this time - I'll decide when camp starts.

EMERGENCY AND MEDICAL INFORMATION

In case of emergency, we will try to reach you on the first or alternate phone number you provided above. Please list up to two additional people and their numbers to contact in case you cannot be reached in an emergency situation.

Emergency name and phone *

Emergency name and phone

List any medication your child is taking. (Any medicines brought to camp must be in their original container.) *

Otherwise, enter "none."

Does your child have any allergies, physical limitations or other special needs? *

If so, please list or explain. Otherwise, write "none."

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. *

Yes ___________________________________

No____________________________________

Signature and date required on first day of camp.

Health insurance carrier *

Group/Policy number *

Hospital preference *

(ex: U of M; St. Joe's; closest hospital; no preference)

Physician's name and phone *

Are camper's immunizations up to date? *

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.

Camper's t-shirt size *

How did you hear about us?

Please let us know whether you learned about our Zoo Camps through local media, from friends, from your child's school, or elsewhere, or if this is a returning camper. Thank you!

ONLY if different from parent listed above, please enter name and email of person who should receive camp information from the Camp Director the week before camp begins. This would normally be the person dropping off the child each day.

Options include Camp After Hours for the week ($75) and Night Crawlers on Thursday evening ($25, or $15 if enrolled in Camp After Hours).

EMERGENCY AND MEDICAL INFORMATION

Payment is due with registration. You may use a credit or debit card.