EmailMe Form - Zoo Camp - June 17th - 21st (Grades 1-3) 2019

Camper's Name *

First Last

Birthdate *

MM / DD / YYYY

Grade (Fall 2019) *

This will be the grade they're entering this fall.

Parent's Name *

First Last

Phone *

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

Alternate Phone (if applicable)

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

Email *

Confirm

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

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

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.

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.

There will be a first aid form to sign on the first day of camp.

Emergency contact name and phone number *

Emergency contact name and phone number

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, enter "none".

Health Insurance Carrier *

Group/Policy Number *

Physician's name and phone number *

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.

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!

Any additional information you'd like to share

Leave blank if there's nothing to add. We look forward to this upcoming camp season! :)

Emergency and Medical Information

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