Application for Enrollment

Camper Information

Last Name _______________________ First Name _________________

Home Address ____________________________________________________

Number and Street City Zip

Home Telephone _______________ Cell Phone __________________

Date of Birth _____________ Grade Entering Aug 08 ______

T-Shirt Size: Sm__ Med__ Lg__ XL__

Parent Information
Father Mother
Name _______________ _______________
Work Phone _______________ _______________
Cell Phone _______________ _______________
Email Address _______________ _______________

Emergency Contact Information (If Parents Can Not Be Reached)

Name _________________ Relationship ____________ Telephone ___________

Medical Information

Family Physician ____________________ Phone ___________________

Current medications ____________________ Allergies ____________________

Specify over-the-counter medications you will permit the personnel to administer to your
child: Ibuprofin___ Tylenol___

I approve of my child’s participation in camp activities and certify that he/she is in good health. I hereby voluntarily assume all risk
of accident or injury to a child which may arise out of his/her participation in camp, completely releasing Robert M. Beren Academy
from any liability that may result from his/her participation. If medical permission is required for illness or injury while attending
camp, I give permission for such care.

Signature of Parent/Guardian _______________________________ Date _____