2005 Discover History Camp Registration Form

2018 Discover History Camp-Registration Form

Camps fill quickly! Please fill out a separate form for each camper. Remember to fill out both pages. Feel free to make copies.

Camper’s Name: ______Age: ____Grade in Fall:____ M or F

Parent/Guardian Names: ______

Address: ______City/St/Zip: ______

Home Phone: ______Cell Phone: ______

Work Phone: ______Email: ______

Emergency Contact ( to be contacted if parents can’t be reached)

Name: ______Phone Number: ______

Relationship to Child:______Cell Phone: ______

Medical Concerns

____Physical Handicaps____Heart Problems____Sensitivity to Sun

____ADD/ADHD____Asthma____Diabetes

____Seizures____Vegetarian____Exercise Induced Difficulties

Other Concerns (Physical or Behavioral) that we should know: ______

Allergies

Describe reactions and management instructions

Insects/ Animals/Plants (list)

______

______

Food (list)

______

______

Will your child need to take medication during the hours they are in camp? Y ____ N _____

Employees of Heritage Hill are not authorized to administer medication except Epipen. Will your child have an Epipen with them? Y ____ N ____

Camper’s additional needs: ______

First time Heritage Hill camper? Y ___ N ___

How did you hear about our Day Camps?

[ ] Social Media [ ] Einstein Expo [ ] ______

Consent Statement: I will not hold Heritage Hill responsible in case of an injury resulting from my child’s participation in a Discover History Camp program, and give consent to my child being given emergency treatment by a physician or hospital as needed. I understand that employees of Heritage Hill are not authorized to administer medication. Specificmedications needed throughout the course of the camps MUST be administered by the child’s parent or guardian. In addition, I understand that during some camps food naturally grown at Heritage Hill is shared with campers as a way to show, instruct, and describe life ways of a particular time period. Should my child be allergic to any foods I will list those under the medical concerns section of this form.

I give consent to allow my child to eat foods supplied. _____ Yes _____ No

______

Guardian SignatureDate

Name of Camp1st Choice Date 2nd Choice Date

1. ______

2. ______

3.______

How to Pay:

Camp registration total$ ______

-10% discount if you sign $ ______

Up 1 camper for 2 or more

Camps OR if you have a

Heritage Hill Membership Card

TOTAL DUE:$ ______

Checks may be made payable to Heritage Hill State Historical Park.

For credit card payments, please call Heritage Hill State Historical Park at 920-448-5150.

Mail completed forms with full payment to:

Heritage Hill State Historical Park/ DHC

2640 S. Webster Ave. Green Bay, WI 54301

Fax: (920) 448-5147

*NOTEHeritage Hill reserves the right to cancel programs at any time for any reason. In this event, refunds will be administered or your child will be moved to their second choice camp if room is available. If the attendee withdraws their registration, refunds will not be available.

ALL PHOTOGRAPHS TAKEN DURING CAMPS MAY BE USED IN HERITAGE HILL BROCHURES OR OTHER ADVERTISING PROMOTIONS