2015 Summer Camp Registration
www.willowell.org | [email protected] | 802.453.6195
All camps run Monday-Friday, Times are as noted.
Please return this completed registration form with a non-refundable $50 deposit to:
The Willowell Foundation, P.O. Box 314, Bristol, VT 05443
Camper Information
Name: _______________________________ Birth Date:_______ Age_______
Gender:_________ Nicknames: __________________________________________
Registering for:
___ Lord of the Rings Camp (ages 9-13), July 13-17th Runs 9:00AM-3:00PM
Number 1st, 2nd, and 3rd choice groups: ___ Dwarves
___ Rangers
___ Elves
___ Coyote Clan Wilderness Adventure Camp (ages 8-12), July 20-24th Runs 9:00AM3:00PM
___ Routed Youth— Manifesting the Most Awesomeness Camp (ages 12-14), August
3rd-7th, Runs 9:00AM- 3:30PM
___ Jedi Training Camp (ages 9-12), June 29th-July 3rd, Runs 9:00 AM-1:00 PM
___ Jedi Padawan Camp (ages 6-8), July 6th-10th, Runs 8:30 AM-12:30 PM
___ Puppets, Nature and Movement Camp (ages 5-8), July 27th-31st, Runs 9:00 AM-12:30
PM
___ Fast Break & Flow Basketball Camp (ages 8-17 in 3 separate divisions), Dates to be
announced, Runs 9:00AM- 2:00PM
Parent/Guardian Contact Information
Name(s):__________________________________________________________
Address: __________________________________________________________
Phone: Home ______________Work ________________ Cell__________________
E-mail: __________________________________________________________
Camp leaders will communicate with parents through email.
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First additional emergency contact (Required):
Name(s): __________________________________________________________
Relationship to camper: ________________________________________________
Phone: _________________________ Additional phone: _____________________
Second additional emergency contact (Required):
Name(s): ___________________________________________________________
Relationship to camper: _________________________________________________
Phone: _________________________ Additional phone: ______________________________________
Any other people authorized to pick up your child from camp:
Name(s): __________________________________________________________
Relationship to camper: ________________________________________________
Phone: _________________________ Additional phone: _____________________
Name(s): __________________________________________________________
Relationship to camper: ________________________________________________
Phone: _________________________ Additional phone: _____________________
Questions
What is the participant excited about in relation to the camp?
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Are there any concerns/fears on the part of the participant or parent in relation to camp?
__________________________________________________________________
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Other comments:
__________________________________________________________________
__________________________________________________________________
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Medical Information
Medical history: Please list allergies, physical limitation(s) and special considerations:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Dietary Restrictions:
__________________________________________________________________
Doctor’s name and telephone:_____________________________________________
Medications:_________________________________________________________
Insurance Carrier:_____________________________________________________
Policy Number: _______________________________________________________
Parent/Guardian Agreements
Medical Waiver*
The camper’s parent/legal guardian warrants that the camper is physically fit and able to participate
in the camp activities, and consents to any employee, agent, or other personnel affiliated with
Willowell to seek medical attention and treatment or other measures deemed necessary or advisable
in the discretion or judgment of Willowell personnel for the above-named camper in the event of an
accident, sudden illness, or other condition that occurs while the above-named camper is in the care
or under the supervision of Willowell. The parent/legal guardian further understands that Willowell
will make reasonable efforts to notify the parent/legal guardian or another parent of the camper in
the case of an accident, sudden illness or other condition, but authorizes Willowell Personnel to seek
such care or treatment, and for any care or treatment to be administered, even in the event that
either parent or legal guardian are not contacted prior to the seeking or rendering of such, care,
treatment, or other measures.
_________________________________________________ _____________
Parent/Guardian signature
Date
Liability Waiver*
I understand that camp takes place in outdoor terrain in rustic conditions, rain or shine, excepting
inclement or dangerous weather. This could include potentially hazardous activities, such as hiking,
fire building, running, playing with foam swords, cooking over a fire, etc.
The parent/legal
guardian agrees to hold harmless the Willowell Foundation and all associated personnel, from any
claims, damages, losses and/or expenses arising out of participation in camp activities and to assume
all liability for any and all personal injury, bodily injury, illness or property damage that occurs as a
result of participation in such camp activities. The parent/legal guardian also warrants that
participation in this camp is voluntary and that the camper and the parent/legal guardian
understand the inherent risks involved in camp activities, and the camper agrees to obey all rules
and policies mandated by camp personnel.
_________________________________________________ _____________
Parent/Guardian signature
Date
*Signature required for participation in camp.
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Photo Release**
I authorize The Willowell Foundation, administrator of summer camps, to publish the photographs
or video taken of my child(ren), and their first name(s) only, for use in printed publications, enewsletters, videos, and on authorized websites (Willowell.org and the AmeriCorps website).
I acknowledge that since my child(ren)’s participation in media produced by the Willowell
Foundation is voluntary, we will receive no financial compensation. I further agree that my
child(ren)’s participation in any media produced by the Willowell Foundation indicates no rights of
ownership whatsoever to me or my child(ren). I release the Willowell Foundation and their
employees/contractors from liability for any claims by me or any third party in connection with their
participation.
_________________________________________________ _____________
Parent/Guardian signature
Date
For Coyote Clan, Jedi Training (8-12),
and Lord of the Rings Camps only: Knife Skills Agreement**
Knife carving will not be an official activity at camp. However, we will teach basic knife safety to all campers
and allow those campers who have parental permission to carve in their own space during free time. Campers
must have a parental signature and parents must provide child with their own knife and a thick leather glove
for their non-carving hand. (This would be their Left hand if they are Right handed.)
I/we wish to have our camper(s) learn safe knife skills and will provide a knife and glove.
_________________________________________________ _____________
Parent/Guardian signature
Date
**Signature not required for participation in camp.
Payment
Full tuition is due 3 weeks before the start of camp.
___ Included is a $50 non-refundable deposit by check. (Required)
Deposit counts toward full tuition.
At this time, I am paying the full tuition: (Please write number of siblings)
___
___
$300: Lord of the Rings Camp (ages 9-13)
$240 Lord of the Rings Camp sibling rate
___
___
$Sliding Scale of $250-$300: Coyote Clan Camp (ages 8-12)
$240 sibling rate
___
___
$250 Routed Youth Camp (ages 12-14)
$230 sibling rate
___
___
$225: Jedi Training Camp (ages 9-12)
$215 sibling rate
___
___
$170 Jedi Padawan Camp (ages 6-8)
$160 sibling rate
___
___
$150: Puppets, Nature and Movement Camp (ages 5-8)
$140 sibling rate
___ $110: Fast Break and Flow Basketball Camp (ages 8-17, in 3 separate
divisions)
$_________ Total amount paid
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Please indicate your full tuition payment method:
___ Check payable to Willowell, mailed to Willowell, P.O. Box 314, Bristol, VT 05443
___ PayPal at www.willowell.org.
Please visit the camp’s page & enter the name of the camp at checkout.
Please contact me about scholarships for families experiencing financial hardship. ___ Yes
Keeping in Touch:
How did you learn about Willowell Summer camps? _____________________________
___ Please keep me up to date on Willowell events and programs!
If for any reason you need to withdraw your child(ren)’s enrollment in camp, we appreciate
notice as early as possible, as the camps often have waiting lists. We will reimburse any tuition
paid above the non-refundable $50 deposit.
Camp leaders will email parents the week before camp starts with details about what to bring
and expect.
Please return this form with $50 deposit to Willowell, P.O. Box 314, Bristol, VT 05443
Find complete information about camps at www.willowell.org
Questions? Contact us at [email protected] or 802-453-6195
Thank you for signing up for camp!
We look forward to welcoming you to the land!
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