Registration Form – Theater in the Woods

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Camper's Name

First

Last

Date of Birth, and Age of Camper as of July 1, 2024

School

Grade

Parent or Guardian

First

Last

Street Address

City

State

Zip Code

Phone

Alternate Phone

Emergency Contact 1

First

Last

Phone

Emergency Contact 1 Phone

Emergency Contact 2

First

Last

Phone

Emergency Contact 2 Phone

Emergency Contact 3

First

Last

Phone

Emergency Contact 3 Phone

Alternate Pickup/Release 1

First

Last

Alternate Pickup/Release 2

First

Last

Alternate Pickup/Release 3

First

Last

Medical Insurance Provider

Medical Insurance Contact Number

Medical Insurance Policy Number

Primary Care Provider

First

Last

Phone

Primary Care Provider Phone

Primary Care Provider Address

Please list any medical problems, including any that require maintenance medication (i.e. diabetes, asthma, seizures)

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason? No/Yes. If Yes, explain: *

Is your child allergic to any type of food or medication? No/Yes. If Yes, explain: *

Does your child require a special diet? Yes/No. If YES, explain: *

Please list any other allergies (insects, seasonal/environmental, animals, asthma); describe reaction and management:

Does your child need an EPI-Pen? No/Yes. If Yes, describe type of allergic reaction, including signs and symptoms of distress: *

Any medication to be self-administered or given by us at camp? Please specify by a written doctor's order with Name of drug and Dosage Frequency

By checking the boxes below, I hereby give permission to give my child over the counter medications according to standard dose:

Tylenol
Ibuprofen
Benadryl

Please note any other OTC medications allowed at standard dose:

Does your child have any special needs - medical, emotional, learning? Provide as much detail as possible.

Please indicate (or call us at 802-235-2050) any situations inside or outside of camp that may affect your child's behavior:

The majority of Theater in the Woods activities take place outside, with exposure to risks normal in outdoor activity. We will safeguard against normal foreseeable risks. At the same time, accidents can occur during the everyday course of events, and it is impossible for us to insure ourselves adequately against such occurrences. Therefore we ask you to take responsibility for providing adequate health insurance for your own child, and that you sign a waiver agreeing to indemnify us for any medical expenses. Your insurance information provided above enables reimbursement to be made for any medical care needed by your child in the duration of our day camp. In case of an emergency, and if a family physician cannot be reached, by checking the box below I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).

I have read and agree to the terms above.

By checking the box below, I agree to hold Theater in the Woods Vermont blameless for any accident or injury which may occur to my child during the course of the camp, except in the case of gross or willful negligence, and I agree to indemnify Theater in the Woods Vermont against medical claims which may arise from my child’s illness, accident or injury.

I have read and agree to the terms above.

I hereby give permission for my child to be photographed during Theater in the Woods Camp. I understand the photos will be used to keep a journal of activities, to share in reports to our supporters, and for promotional purposes including flyers, brochures, and on the internet. I understand that although my child's photograph may be used for advertising, his or her identity will not be disclosed

I hereby give permission for the transportation of my child for Theater in the Woods activities by modes of transportation agreed to by the camp directors. *

Tuition for Bobcats or Wolves camp is $650. Tuition for one-week Bears camp is $325. I agree that I will use the payment button below to pay the full fee or a deposit of $200 upon submission of this form. I agree that I will pay the balance of $450 due by July 1, 2024 for Bobcats' camp or by July 22, 2024 for Wolves' camp, or the balance of $125 for Bears' camp by June 24, 2024. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. I agree to the tuition payment terms.

I agree to the above tuition payment terms.

Camp Selection

Electronic Signature

First

Last

Check here if you will be mailing a check to accompany this form.

I will be sending check by mail.

PLEASE MAKE SURE TO PRESS SUBMIT BEFORE PROCEEDING TO PAYPAL