Springbrook Freshmen Camp Registration Form
Registration Information
Student name
Medical Information:
Address:
City, State, Zip
Gender
Parent/Guardian
Physician’s Name
Physician’s Phone #
Date of Birth
Health Insurance Provider
Home
Named of Person Insured
Phone #
Group#
Business Phone #
Policy #
Are all immunizations current?
Y
Cell Phone #
email address
Emergency Contact (In the event that we are unable to contact you)
Shirt information
Please indicate size
Youth Small
Home Phone #
Cell Phone #
Please list any medical conditions of which staff
should be aware. Please include medication
information if applicable:
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult X-Large Adult XX-Large (add $1.00)
This section must be completed and signed by the parent/guardian to insure acceptance into the program. I verify
that you have my permission to take my child to the nearest medical facility for emergency treatment if needed. I
verify that my son/daughter will be responsible for all MCPS behavioral guideline, and I understand that my child may
be dismissed from the camp for violating any MCPS behavioral policy.
Signed
Date
Payment Information
Cost for the week long, half day camp:
$100
Makes check/money order payable to: Springbrook High School (write: Camp-Last Name-on the memo line)
Send Payment to:
John Weinshel
Springbrook High School
201 Valley Brook Dr.
Silver Spring, MD 20904
N