2020 Summer Adventure Camp Registration
Section 1: Camper Information (Please complete a separate form for each camper you are registering) Camper Last Name Camper First Name Date of Birth Camper's Primary Street Address City State Zip Code
Section 2: Parent/Guardian Information (This person will serve as the primary contact; they are also the primary emergency contact & they are an authorized driver) Parent/Guardian Last Name Parent/Guardian Last Name Parent/Guardian First Name Parent/Guardian First Name Relation to Camper Relation to Camper Email for Confirmation Email for Confirmation How did you hear about Beech Creek Adventure Camp? How did you hear about Beech Creek Adventure Camp? Primary Phone Primary Phone Secondary Phone Secondary Phone
Different Residence than Camper?
If yes, complete address below
Different Residence than Camper?
Parent/Guardian Street Address Parent/Guardian Street Address City City State State Zip Code Zip Code
Section 3: Additional Parents/Guardians & Emergency Contact Information (Please provide at least one additional emergency contact in this section, different than the primary contact listed above) Last Name First Name Relation to Camper Primary Phone Secondary Phone Last Name First Name Relation to Camper Primary Phone Secondary Phone Last Name First Name Relation to Camper Primary Phone Secondary Phone
Section 4: Camper Health & Medical Information (Select all that apply) If your child has an allergy, please specify the allergy here. If your child has any existing conditions, please explain them here. List any addtional specific medical, physical, emotional, or behavioral conditions that need to be considered. List any medications your child will be bringing to camp. Please explain any reasons your child's activity should be limited. In the event that paramedics are called please list all medications currently taken by your child. Medication Name Dosage How often? Time Taken Reason Taking Medication Name Dosage How often? Time Taken Reason Taking Medication Name Dosage How often? Time Taken Reason Taking Medication Name Dosage How often? Time Taken Reason Taking
Section 5: Camp Dates Attending (Select all that apply)
Please select only the camp dates that you paid for during online checkout.
If a camp date you had wanted to register for reached its limit during checkout, please indicate if you would like to be added to the waiting list by completing the wait list section.
Wait List (Only complete this section to be added to the waiting list for full camp dates. We will contact you if a space becomes available.) Section 6: Waivers & Signature
Beech Creek Botanical Garden & Nature Preserve is a natural environment with potential allergens such as trees, plants, flowers, bees, etc. In addition, Beech Creek Botanical Garden & Nature Preserve is not a peanut-free environment. While we do our best not to offer nuts, we cannot protect against exposure to these allergens. If your child is susceptible to allergic reactions please be sure that you have taken all necessary precautions, including providing complete and thorough medical information and notifying our staff of your child’s allergies.
General Release of Liability and Authorization for Treatment
This health information is correct to the best of my knowledge and the camper herein described has permission to engage in all camp activities, except as noted. In consideration for being allowed to participate in the Beech Creek Gardens programs, I agree to assume the risk of such activities and programs and further agree to hold harmless Beech Creek Gardens and its staff members conducting the activities from any and all claims, suits, losses, or related causes of action for damages including, but not limited to, such claims that may result from injury or death, accident or otherwise, during or arising in any way from the activities. I grant permission for my child to participate in all planned camp activities, understanding that competent leadership is provided. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp staff to secure and administer treatment, including hospitalization, for my child as named above. I acknowledge that this General Release of Liability and Authorization for Treatment is legally binding on me personally and on my heirs, personal representatives, successors, and assignees. Beech Creek Gardens is not responsible for lost, stolen, or damaged personal articles.
I authorize Beech Creek Gardens and its assignees to use any photograph, picture, or likeness of me or my child for promotional purposes.
Notice of cancellation must be received in writing at least 10 days prior to the scheduled camp date to receive a refund. You will be refunded the camp fee minus a $20 processing fee. No refunds will be issued with less than 10 business days notice. Beech Creek Gardens will only cancel a camp due to severe weather warnings and extremely high winds.
Use your mouse or finger to draw your signature in the box above. Please review your answers for accuracy before submitting your form. Submit