St. John Ranch and Lodge :: Summer Camp Enrollment Application

Camper Information

* Camper's Full Name:

* Date of Birth:

* Street Address:

* City:

State:

* Zip:

* Insurance Company:

* Phone Number:

Mother's Information

* Mother's Name:

* Street Address:

* City:

State:

* Zip:

* Home Phone:

* Work Phone:

Cell / Mobile Phone:

Occupation:

Work Hours:

Father's Information

* Father's Name:

* Street Address:

* City:

State:

* Zip:

* Home Phone:

* Work Phone:

Cell / Mobile Phone:

Occupation:

Work Hours:

Camper Details

Religious Preference:

Height:

Weight:

Grade:

Riding Experience:

Special Interest(s):

Special Need(s):

Other Camp(s) Attended:

* Session Preference

WEEK ONE	MAY 31 - JUNE 6	Campers attending one week only must attend week one or week five
WEEK TWO	JUNE 7 - 13	For campers attending two or more weeks
WEEK THREE	JUNE 14 - 20	For campers attending two or more weeks
WEEK FOUR	JUNE 21 - 27	For campers attending two or more weeks
WEEK FIVE	JUNE 28 - JULY 4	Campers attending one week only must attend week one or week five

I certify that the above information is true and correct to the best of my knowledge. I also certify that I am the parent and/or legal guardian of the above named child and that my child wants to attend the St. John Ranch and Lodge Summer Camp. I agree that the child listed above will cooperate fully with all camp rules. By signing below, I give authority to St. John Ranch and Lodge full permission for emergency medical care if sound reason and the facts indicate that it is necessary.

*Signature: *Your Email Address: Date: 01/05/2009

APPLICANT AUTHORIZATION: BY MY SUBMITTING THIS FORM ACCEPT AS NOTICE IN WRITING OF AND AGREE THAT I WILL BE HELD FULLY RESPONSIBLE FOR ANY AND ALL MEDICAL BILLS FOR THE ABOVE NAMED CHILD IN CASE OF EMERGENCY

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