Parent/Guardian

Parent/Guardian

Address

City

State

Zip

Email

Home Phone

Person to contact in case of emergency

Emergency contact numbers       (O)

(H)

Camp Tall Timbers Try-Out Weekends Registration Form

Weekend (check one)

Camper Name

Gender

Birth Date

Age

Grade (09-10)

June 26th & 27th

July 24th & 25th

$100, which will be credited towards any 2011 summer session for all campers who enroll.

Payment is requested upon registration, 100% refundable with 24 hours notice.

Fee:

Does your child (or has your child during the school year) require any chronic medication?

If Yes, please describe

Transportation will be provided from Rockville, MD at 10am, Tysons Corner, VA at 11am, and Baltimore, MD at 10am, and return to Rockville at 5pm, Baltimore at 5pm, and Tysons at 4pm.  You are also welcome to drive your child to and from camp.  Please indicate your travel plans below:

Arrival

Departure

Rockville

Tysons Corner

Baltimore

Parent

Rockville

Tysons Corner

Baltimore

Parent

It is understood that the camp has the right to use whatever pictures may be taken at camp for the purposes of promoting camper enrollment and/or in advertising the camp.  I/We understand that campers are not permitted to have cell phones in camp.  “My child has permission to participate in all activity while at camp this summer, including, but not limited to, horseback riding, trampoline and other gymnastic programs and hockey, football and other field sports.  I agree that the Camp will not responsible for any injuries that may be sustained by my child while participating in any activity at Camp unless such injury is directly caused by the gross negligence or willful acts of the Camp.  In case of a medical emergency, I understand every effort will be made to contact parent or guardian of the camper.  If I cannot be reached, I hereby give permission to the Physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child.  I further assign all medical payments directly to said Doctor and/or treating facility.”

I/We have read and agree to the terms contained in this document.

Mother’s Signature

Father’s Signature

For additional information call Glenn Smith or Emma Hully toll-free at 1-800-862-2678