"LIFE IS GOOD"  REGISTRATION FORM

3rd - 5th Grade Retreat

Rockin'C Ranch ~ September 24-25, 2010

 

Child's Name:         Grade:       Date of Birth:                  

Parent(s)/Guardian Name(s):   email:

Street Address:      City:        Zip:   

Home Phone:          Cell Phone:       Other Phone :      

Other Emergency Contact:     Relationship to Camper:   

Emergency Contact Phone #:       Will this be your child's first camp experience?  Yes   No

Can your child swim?  Yes    No     Indicate proficiency:         

The following activities are available at Rockin' C - although we will probably not take advantage of these activities during this retreat - for your information they are listed as follows:  Swimming, High Ropes Course, Zipline, Canoes/Kayaks, Horseback Riding (in arena only). 

Is your child allowed to participate in all of the activities (if they choose to)?      Yes    No

If no, please indicate which activities they may not participate in:    

List any medications your child will be taking while on the retreat and specific dosage instructions:      

 

Should your child need basic medical attention, please mark the appropriate over-the-counter medication(s) that are approved for your child:        Tylenol          Motrin            Neosporin (for scrapes/minor cuts)    

Entering your name here is deemed legal permission for your child to participate:

Payment Information (please choose from the drop-down box below: