Registration Form

9 a.m. - 4 p.m., M-F

$250 per child/week

10% sibling discount

After-Camp Care available (4-5 p.m.) for $25 per week

REGISTRATION

2017 camp wind eagle

At Historic Yates Mill Park, 4620 Lake Wheeler Road, Raleigh

Student's Name *

First

Last

Student 2 *

First

Last

Grade *

Phone Number *

Parent/Guardian's Name *

Cell Phone Number *

Address *

City *

Email *

Which camps will your child(ren) be attending? *

July 10-14 (rising K-5)

Parent/Legal Guardian Medical Emergency Authorization

In the event of a medical emergency while my child is participating in C.H.E.R. camp activities, I authorize program officials to release the following information to the healthcare provider. I understand officials will use the contact information provided below to contact me in the event of such an emergency. If any emergency medical procedures or treatment are required and I am unavailable to be contacted, I consent to the C.H.E.R. supervisor(s) arranging for and consenting to the emergency procedures or treatment on the advice of qualified medical personnel. I will pay the costs of any such medical procedures or treatment.

I understand that accidents can unexpectedly happen, and I agree to hold harmless the program officials unless there is proof of direct negligence and intent to harm. I understand there will be water activities including canoeing and fishing. *

Agree

#1 Emergency Contact *

#1 Contact Number *

#1 Alternate Number (optional) *

Physician *

Date of Last Tetanus Booster *

Student Health Concerns/List of Allergies *

#2 Emergency Contact *

#2 Contact Number *

#2 Alternate Number (optional) *

Physician's Number *

Please list any medications taken routinely *

Name of Insurance Co. *

Policy # *

I _____ give permission for the use of the student's image in print or digital media. Names will not be included. *

Do Do Not

Please Select One Option *

Pay Below with PayPal Mail Check to: C.H.E.R., 6814 Fayetteville Rd., Raleigh, NC 27603

Hit 'Submit' below to send C.H.E.R. your application. Please be prepared to sign the below portion on Day 1 of your child's camp. Each child should bring their lunch and a water bottle. We provide the water and journals/pencils, snacks, etc.
We look forward to seeing you this summer!

I request that the below named student be allowed to participate in planned activities with C.H.E.R. and give my specific consent for their participation.

Parent/Guardian Signature: _____________________________________________ Date: ___________________

Note! You must be present on Day 1 of your child's camp to provide us with your signature. Without a signed form, students can not be allowed to participate in activities.

If you have any additional questions, please call or email us.
(919) 270-9682
humanearthrestoration@gmail.com

Submit

REGISTRATION ​​2017 camp wind eagle

REGISTRATION

2017 camp wind eagle