REGISTRATION FORM
Please send application and check to: Paul Vachon Cost: $20010 Gagne Street Augusta, Maine 04330 Dates: July 12-16
CAMPER NAME____________________________________________ ENTERING GRADE __________
MAILING ADDRESS ________________________________________________ T-shirt Size _________________
PHONE NUMBER _____________________________________
EMAIL ADDRESS (EMAIL WILL BE USED TO CONFIRM APPLICATION) _____________________________
EMERGENCY CONTACT INFORMATION (SOMEONE WHO CAN BE REACHED DURING THE DAY)
NAME _______________________________________ PHONE NUMBER _________________________________________
I give permission to Capital City Clinic to take pictures of my child and use the images to promote Capital City Clinic.
______________________________________ ___________________________
Parent / Guardian Signature Date
In case of emergency (medical), I understand every attempt will be made to contact the parent or guardian of the camper. If they are unreachable, I give permission to the Capital City Clinic to ensure medical treatment for my child. I assume the risk of injury to my child, or loss or property, and will make no claim against the Capital City Clinic or its' staff.
________________________________________ __________________________
Parent / Guardian Signature Date
Allergies or Medical needs our trainer should be aware of ______________________________________
________________________________ _________________________ ___________________________
Health Insurance Co. Subscriber's Name Certificate #
