Winter Weekend 2018 Camper Application

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* 1. Camper Information (please complete a new application for each camper)

Name

Age (min of 11 by 01/05/18)

Gender

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* 2. Parent/Guardian Information

Name

Email Address

Phone Number

Mailing Address

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* 3. Emergency Contact Information #1

Name

Phone Number

Email

Relationship to Camper

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* 4. Emergency Contact Information #2

Name

Phone Number

Email

Relationship to Camper

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* 5. Does your camper have any dietary restrictions? If yes, please explain

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* 6. Does your camper have any allergies?

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* 7. Please list any Camper medications and other pertinent medical information

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* 8. Please list any adults that have permission to pick up your camper from camp.

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* 9. Quinipet Camp & Retreat Center ________ have permission to use photographs of my camper in any promotional and social media postings.

Does

Does Not

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* 10. Payment is due by 01/03/18. I would like to pay the $250 Winter Weekend Camper fee by:

Check/Money Order

Credit Card (AMEX, Visa, Mastercard) - We will contact you to process this charge over the phone