ONLINE REGISTRATION FORM

Use this form to register your child. Information in bold is required and must be supplied in order to submit the form.

A deposit of $200 by credit card is also required.  Your registration will be submitted when you press the "send registration" button at the end of the form.  Complete one copy for each child you wish to register.

If you prefer to register your child by mail, you may print this form and mail it along with your deposit of $200 by check to the address listed on the form.  Complete one copy for each child you wish to register.  If you would like to pay by credit card, click on the PayPal icon on the following page and follow the simple directions.

      Your Name: 
                  First Last

    Your E-mail: 


REGISTRANT INFORMATION

  Name of Camper: 
                  First Last
       Nickname: 

  Date of Birth: 
                 MM/DD/YY

            Sex: Male 
                 Female

         Height:  (feet-inches)
         Weight:  lbs.
Grade in School:  (for '05-'06)
 Type of School: 
(Public, Private, Montessori, Religious, Other)
Has he or she attended a summer camp
before?
  Yes
  No

Can He/She Swim
  Yes
  No

Can He/She ride horseback?
  Yes
  No

Sports/Talents/Hobbies:


Special Needs (diet, allergies, etc.):


What would you like your child to accomplish
at camp:


Please list any person(s) that you authorize to
visit and/or pick-up your child from camp. Under
NO circumstances will any individual that is not
authorized by you be allowed on the premise.
1. 
2. 
3. 
4. 

PARENT INFORMATION

Name of Parent: 
                 First Last

       Address: 
          City: 
         State: 
           ZIP: 

    Home Phone:  (w/area code)
    Work Phone:  (w/area code)
           Fax:  (w/area code)
        E-mail: 

How did you hear of Camp Indecon:


Comments:

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