CAMPER INFORMATION
 

Last Name:    First Name:

Gender: Male   Female               SPAUSA Member: Yes   No
                                                            (Required for some activities)
                        mm/dd/yyyy
Date of Birth:     Age:     Grade Completed:

Mailing Address:

City:    State:    Zip Code:

E-mail Address:

Residence: Farm   Rural (<10,000)   Town (10-50,000)   City (50,000+)

Mother/Guardian:

Home Phone:    Work Phone:    Cell/Beeper:

Father/Guardian:

Home Phone:    Work Phone:    Cell/Beeper:

Camper Lives with: Mother   Father   Other (explain)
 

EMERGENCY CONTACT (other than parents/guardians listed above)

Name:    Relationship:

Day Phone:    Evening Phone:    Cell/Beeper:

Address:

CAMP CRAZY AT MT. MADNESS ADVENTURE CENTER, LLC

Please indicate which camp session(s) you would like your child to attend. We encourage campers to participate
in each of our programs! Space is limited--please reserve early.

Day Camp -- Ages 8 - 15 -- Monday - Friday -- 8am - 4pm
(Early drop-off 6:30/ Late pick-up 5:30 $10 each) Lunch Included

CAMP FEES (as calculated from above registration)

   Session Fees:                             BALANCE/TOTAL
    Subtotal:                                     DUE BY First Day of Camp:
    Minimum $45 Deposit:                

Are you receiving financial assistance? No   Yes -- Name of Agency:
                               

Parent/Guardian Signature:
By signing here I agree that this form has been accurately completed, and I give my child permission to participate in all camp
activities during his/her session(s).

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