Registration Form

Reaching for the Peaks – Summer Camp

Registration Form

Participant Name ___________________________________________

Date of Birth ____________________ Grade ______    Female    __    Male    __

Address ___________________________________________________

Day Phone ______________________ Cell Phone __________________

Name of Physician ____________________ Phone Number ____________

Med. Insurance Carrier _________________ Policy # ________________

Subscriber Name _____________________________________________

Emergency Contacts:

Name _________________________________ Relation _____________

Day Phone ______________________ Cell Phone ___________________

Program Dates: (please indicate in which session your child will participate)

July 8th – July 11th  (9:00 – 3:00, Wednesday 9:00 - 4:00)  ___

July 15^th – July 18^th (9:00 – 3:00, Wednesday 9:00 - 4:00)   ___

July 22nd – July 25^th (9:00 – 3:00, Wednesday 9:00 - 4:00)  ___

Please Note: these are four day sessions.

Health Questionnaire:

Is your child taking any medication? ___ Yes   ___ No

(Please list and explain all medications the participant is taking)

Additional comments to Carrie and Meike (allergies, special needs, etc…)

Waiver and Medical Authorization

In the event of any illness or injury, I hereby consent to whatever x-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care are considered necessary in the best judgment of the attending physician, surgeon, or dentist and performed by or under the supervision of a member of the medical staff of the hospital or facility furnishing medical or dental services.

I understand that I hold Carrie Morgan and Meike Wanberg harmless from any and all liability or claims, which may arise out of or in connection with my child’s participation in this activity.

Parent Signature ___________________________________________

Date ____________________________________________________

Complete by May 15^th and send with $100 deposit to:

Carrie Morgan

40 Portola Lane

Mill Valley, Ca 94941

or

Meike Wanberg

5 Valley Road

San Anselmo, Ca 94960