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

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

Parent/Guardian Information

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* 2. Parent/Guardian Information

Emergency Contact Information #1

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* 3. Emergency Contact Information #1

Emergency Contact Information #2

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* 4. Emergency Contact Information #2

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

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

Does your camper have any allergies?

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* 6. Does your camper have any allergies?

Please list any Camper medications and other pertinent medical information

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

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

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

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

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

I would like to pay the $225 Winter Weekend Camper fee by ______

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* 10. I would like to pay the $225 Winter Weekend Camper fee by ______

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