Winter Weekend 2017 Camper Application Question Title * 1. Camper Information (please complete a new application for each camper) Name Age Gender Question Title * 2. Parent/Guardian Information Name Email Address Phone Number Mailing Address Question Title * 3. Emergency Contact Information #1 Name Phone Number Email Relationship to Camper Question Title * 4. Emergency Contact Information #2 Name Phone Number Email Relationship to Camper Question Title * 5. Does your camper have any dietary restrictions? If yes, please explain Question Title * 6. Does your camper have any allergies? Question Title * 7. Please list any Camper medications and other pertinent medical information Question Title * 8. Please list any adults that have permission to pick up your camper from camp. Question Title * 9. Quinipet Camp & Retreat Center ________ have permission to use photographs of my camper in any promotional and social media postings. Does Does Not Question Title * 10. I would like to pay the $225 Winter Weekend Camper fee by ______ Check/Money Order Credit Card (AMEX, Visa, Mastercard) - We will contact you to process this charge over the phone Done