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2012 page 1 of 1 www.gshnj.org
Complete this form and mail with payment to: Girl Scouts Heart of New Jersey, Attn: Camp Support, 201 Grove Street East, Westfield NJ, 07090
Camper’s Name: _________________________________________________ DOB: _____/_____/________ Grade in Sept 2012: ___________
Is your daughter a registered GS for the 2011/12 year? Y____N___ Level: _______ Troop#:________ SU#:_____ Council: _______________
Camper’s Address: _____________________________________ City: ____________________ State: _______ Zip Code:________________
Custodial Parent /Guardian Name: ______________________________________________ E-mail: ____________________________________
Cell#: _________________________________ Work#: ________________________________ Home#:________________________________
Second Parent /Guardian Name: ________________________________________________ Home#: ___________________________________
Cell#: _________________________________ Work#: ________________________________ E-mail#:________________________________
NOTE: The Custodial Parent’s e-mail and Camper’s address will be used for camp correspondence unless otherwise noted. PROGRAM REGISTRATION – Second choices increase our ability to serve you.
Camp Hoover Session Program Name 1st Choice Program Name 2nd Choice Stayover Check for Yes 1 July 8 – July 14 Stayover 1-2 July 14 – July 15 2 July 15 – July 21 Stayover 2-3 July 21 – July 22 3 July 22 – July 28 Stayover 3-4 July 28 – July 29 4 July 29 – Aug 4 Stayover 4-5 Aug 4 – Aug 5 5 Aug 5 – Aug 11 Stayover 5-6 Aug 11 – Aug 12 6 Aug 12 – Aug 18
Friend Request: _________________________________________________ Only one Friend. Friend must be registered for the same program and session, and be of the same age/grade. All requests must be mutual.
PAYMENT INFORMATION – Balance due May 16, 2012
Non-refundable deposit: $60 per session X _____sessions OR full program fee (required if registering after May 16, 2012) $______________ Girl Scout Fee: $12 Membership (if not registered, membership yr is Oct. 1st - Sept. 30th). This fee is not refundable $______________ Tax deductible contribution: your gift, in any amount, helps a girl in financial need benefit from a week of camp. $______________ Total Amount enclosed: $______________
Circle Payment Method: Check (Make payable to GSHNJ) Money Order/Certified Check Visa MC Discover AMEX
Card#: ____________________________________________ Exp Date: _____________________ Zip Code: _________________
Cardholder Signature:_______________________________________________________________________________________
I have read and understand the Girl Scout Heart of New Jersey 2012 Camp Brochure and agree to cooperate with all regulations, including refund polices. I give my permission for my camper to participate in all phases of the camp program and activities as described in the camp brochure, and online, both on and off property. I consent that my camper may be photographed, videotaped and/or recorded and that the electronic images/recording may be made public and used for promotion of Girl Scouting, free of any claims. I acknowledge that the camper will make the Girl Scout Promise and accept the Girl Scout Law. The camper, if not already a member, has our permission to join Girl Scouts. I understand that all balances and camp forms are due by May 16th, 2012. Parent/Legal Guardian Signature:_____________________________________________________ Date: ______________________
…2012 Resident Camp Registration…
2012 page 1 of 2 www.gshnj.org
Complete both sides of this form and mail with payment to: Girl Scouts Heart of New Jersey, Attn: Camp Support, 201 Grove St East, Westfield, NJ 07090 Camper’s Name: _________________________________________________ DOB: _____/_____/________ Grade in Sept 2012: ___________
Is your daughter a registered GS for the 2011/12 year? Y____N___ Level: _______ Troop#:________ SU#:_____ Council: _______________
Camper’s Address: _____________________________________ City: ____________________ State: _______ Zip Code: ________________
Custodial Parent /Guardian Name: ______________________________________________ E-mail: ____________________________________
Cell#: _________________________________ Work#: ________________________________ Home#:________________________________
Second Parent /Guardian Name: ________________________________________________ E-mail: ___________________________________
Cell#: _________________________________ Work#: ________________________________ Home#:________________________________
NOTE: The Custodial Parent’s e-mail and Camper’s address will be used for camp correspondence unless otherwise noted. PROGRAM REGISTRATION – Second choices increase our ability to serve you.
CAMP DEWITT The OVAL After Session Program 1 Program 2 Care
Session Program 1 Program 2
1 June 25 – June 27 1 July 2 – July 6 2 July 2 – July 6 2 July 9 – July 13 3 July 9 – July 13 3 July 16 – July 20 4 July 16 – July 20 4 July 23 – July 27 5 July 23 – July 27 5 July 30 – Aug 3 6 July 30 – Aug 3 6 Aug 6 – Aug 10 7 Aug 6 – Aug 10
Circle T-Shirt Size: Child SM Child MED Child LG Adult SM Adult MED Adult LG Adult XLG Adult XXLG
Bus Stop Number: ________ Bus Stop Town: _________________________ I will drive my camper to and from camp:
Friend Request: __________________________________________________ Only one Friend. Friend must be registered for the same program and session, and be of the same age/grade. All requests must be mutual.
PAYMENT INFORMATION – Balance due May 16, 2012 Non-refundable deposit: $60 per session X _____sessions OR full program fee (required if registering after May 16, 2012) $______________ Girl Scout Fee: $12 Membership (if not registered, membership year is Oct. 1st – Sept. 30th). This fee is not refundable. $______________ Tax deductible contribution: Your gift, in any amount, helps a girl in financial need benefit from a week of camp. $______________ Total Amount enclosed: $______________
Circle Payment Method: Check (Make payable to GSHNJ) Money Order/Certified Check Visa MC Discover AMEX
Card#: ____________________________________________ Exp Date: _____________________ Zip Code: _________________
Cardholder Signature:_______________________________________________________________________________________
I have read and understand the Girl Scout Heart of New Jersey 2012 Camp Brochure and agree to cooperate with all regulations, including refund polices. I give my permission for my camper to participate in all phases of the camp program and activities as described in the camp brochure and online, both on and off property. I consent that my camper may be photographed, videotaped and/or recorded and that the electronic images/recording may be made public and used for promotion of Girl Scouting, free of any claims. I acknowledge that the camper will make the Girl Scout Promise and accept the Girl Scout Law. The camper, if not already a member, has our permission to join Girl Scouts. I understand that all balances are due by May 16, 2012. Parent/Legal Guardian Signature:_____________________________________________________ Date: ______________________
…2012 Day Camp Registration Form…
2012 page 2 of 2 www.gshnj.org
CAMP DEWITT THE OVAL
Camper’s Name: _________________________________________________ DOB: _____/_____/________ Grade in Sept 2012: ___________
Do both parents have custody? Yes No If not, who is the custodial parent ______________________________________________
EMERGENCY CONTACT – Please inform these people. Full Name: __________________________________________________________ Relationship to Camper: ______________________________
Cell#: ___________________________ Work#: ___________________________ E-mail:____________________________________________
Full Name: __________________________________________________________ Relationship to Camper: ______________________________
Cell#: ___________________________ Work#: ___________________________ E-mail:____________________________________________
CAMPER RELEASE – In addition to custodial parent, legal guardian, or emergency contact, list adults permitted to pick-up your child.
Full Name: __________________________________________________________ Relationship to Camper: ______________________________
Full Name: __________________________________________________________ Relationship to Camper: ______________________________
HEALTH HISTORY DATE DISEASE DATE DISEASE CHECK ALLERGIES Frequent Ear Infections Chronic or recurrent illness Insect stings / reaction
Heart Defect / Disease Diabetes 1) Glucose testing? yes no *____________________
Convulsions 2) On insulin? yes no Food allergies / reaction
Blood Disorders Asthma 1) Use of inhaler? yes no *___________________
Hypertension 2) Self administer? yes no *Prescribed Epipen? yes no
Psychiatric Treatment Seizures 1) Most recent _____________________ *Can child self-administer Epipen?
Mononucleosis 2) List medications __________________ yes no **DATE OF LAST TENANUS SHOT: ___________________ (month /year) Circle any Allergies: Penicillin, Other Drugs (be specific), Poison Ivy, Hay fever, Other drugs/ allergies ____________________________________________________ If your child needs an Epipen, you must contact the Health Administrator prior to camp.
MEDICATION TAKEN ROUTINELY________________________________________________________________________________________________________ DISABILITY OR HEALTH CONDITION LIMITING ACTIVITIES ____ HOSPITALIZATION / OPERATIONS / INJURIES ANYTHING THAT WE NEED TO KNOW ABOUT YOUR CHILD ARE THERE ANY ACITIVITES YOUR CAMPER SHOULD BE EXEMPTED FROM FOR HEALTH REASONS:_____________________________________________ FOR FEMALE Has she menstruated? yes no; If not, has she been told about it? yes no
MEDICATION I hereby give permission for the Day Camp Director, Health Administrator, or Nurse to administer to my child Over-the counter medications if the Day Camp Director, Health Administrator or Nurse deems it necessary. Dosages will be administered according to directions on the bottles OR by the Camp Physician’s standing orders OR unless a physician directs otherwise. EMERGENCY MEDICATION I hereby give permission to the medical personal selected by the Day Camp Director or Health Administrator to provide routine health care; to administer medications; to order x-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give my permission to the physician selected by the Day Camp Director or Health Administrator to secure and administer treatment including hospitalization, and to order injections and/or anesthesia and/or surgery for the person named above.
This health history is correct as far as I know. All immunizations required for school are up to date. The person herein described has my permission to engage in all prescribed activities except as noted by a physician. This completed form may be photocopied for trips out of camp. I have carefully read and understand the contents of this document. Date Custodial Parent or Legal Guardian Signature Print Custodial Parent or Legal Guardian Name
>>>2012 Day Camp Medical Form>>>
NOTE: The following items must be attached at time of registration. A current copy of immunization records, a current copy of insurance card (front & back), and photo taken within the last six months.
Last Name __________________________, First Nam
e _____________________ MI ______
