Kingsbury Club & Spa Camp Registration

CAMPER'S NAME:	*
BIRTHDATE:
ADDRESS:
CITY:
STATE:
ZIP:
PARENT/GUARDIAN:
HOME PHONE:	*
WORK PHONE:
EMAIL:	*
MEMBERSHIP TYPE:	All Inclusive     Other Member     Non-Member
PAYMENT METHOD:	House Charge     Check     Credit Card
CAMP:	The Camp at Kingsbury     Kiddie Camp
KIDDIE CAMP SESSIONS:	Session 1: June 28 - July 2 Session 2: July 5 - July 9 Session 3: July 12 - July 16 Session 4: July 19 - July 23 Session 5: July 26 - July 30 Session 6: August 2 - August 6 Session 7: August 9 - August 13 Session 8: August 16 - August 20
THE CAMP AT KINGSBURY SESSIONS:	Session 1: June 28 - July 2 Full    Half Session 2: July 5 - July 9 Full    Half Session 3: July 12 - July 16 Full    Half Session 4: July 19 - July 23 Full    Half Session 5: July 26 - July 30 Full    Half Session 6: August 2 - August 6 Full    Half Session 7: August 9 - August 13 Full    Half Session 8: August 16 - August 20 Full    Half
T-SHIRT SIZE:	Youth S      Youth M      Youth L
Please explain any medical conditions or restrictions we should be aware of:

Please note: Parent/Guardian will be required to sign the folIowing:
I accept fully that the Kingsbury Club, its shareholders, directors, officers, employees, representatives and agents cannot be held responsible for any and all loss, claim, injury, damage, or liability sustained or incurred by my child during their participation on premises or off.
In the event I cannot be reached in an emergency, I hereby give permission for the Kingsbury Club to secure proper treatment for my child.

All campers are required to fill out a medical form provided by The Kingsbury Club.