Registration Track-Out

9 a.m. - 4 p.m.

M-F

$250/child/week

10% sibling discount

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

payment button located under registration submit button

REGISTRATION FORM

2018 Camp Wind Eagle Track-Out Program

* Indicates required field

Student's Name *

First

Last

Grade *

Parent/Guardian's Name *

First

Last

Contact Phone Number *

Contact Email *

Address *

City *

Which week will your student attend? *

Track 4: July 16-20 Track 3: August 13-17 Track 2: August 20-24

PLEASE READ: 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 procedure or treatment are required and I am unable 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 evidence of direct negligence and intent to harm. I understand there will be water activities including canoeing and fishing. *

Agree

#1 Emergency Contact *

First

Last

#2 Emergency Contact *

First

Last

#1 Emergency Contact Phone Number *

#1 Alternate Number (optional) *

#2 Emergency Contact Phone Number *

#2 Alternate Number (optional) *

Physician Name *

First

Last

Physician Phone Number *

Date of Last Tetanus Booster *

Student Health Concerns/List of Allergies *

Please list any medications taken routinely. *

Name of Insurance Co. *

Insurance Policy # *

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

Do Do Not

Please indicate method of payment. *

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

Hit 'Submit' below to send C.H.E.R. your application. Please be prepared to sign our consent form on Day 1 of camp.
Without a signed form, students can not be allowed to participate in activities.

Each child should bring their lunch and a water bottle each day.
We provide the water and journals/pencils, snacks, etc.
We look forward to seeing you this summer!

Submit

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

9 a.m. - 4 p.m.M-F$250/child/week10% sibling discountAfter-Camp Care available (4-5 p.m.), for $25/child/week**payment button located under registration submit button**

REGISTRATION FORM​2018 Camp Wind Eagle Track-Out Program

9 a.m. - 4 p.m.

M-F

$250/child/week

10% sibling discount

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

payment button located under registration submit button

REGISTRATION FORM

2018 Camp Wind Eagle Track-Out Program