REGISTRATION CAMP#______________

PLEASE FILL OUT THE FORM AND RETURN IT WITH YOUR PAYMENT BY

JUNE 1

Forms may be mailed to Stratford Historical Society, PO Box 382, Stratford Ct. 06615

or dropped off at the society Monday -Friday 8:30-1:30.

Please write separate checks for the membership and camp fee.

History Camp Week: $150 per child One adult membership: $20 per family

CAMPERS

NAME___________________________________________________________

Male/Female-Birth Date

Parent(s) Name(s)

_

Address

Home Phone

Cell Phone

E-Mail Address

Emergency Person and Numbers:

1.

2.

3.

No one may pick up your child unless they are on this list. Children MUST be signed IN

and OUT each day!!!!

Please list any allergies or concerns which may affect your child's experience at camp.

Your signature on the bottom of this form allows us to seek medical treatment in case of

an emergency.

I authorize any licensed physician to provide any proper medical treatment in the event of

an emergency. I under stand this authorization is given prior to any need for medical care

and is given to avoid unnecessary delay for emergency treatment which the physician

may deem advisable in the exercise of his/her best judgment. I assume a reasonable

attempt will be made to contact me. I authorize the Stratford Historical Society Camp

Staff to call the Stratford EMS for transportation away from the program to the nearest

medical facility.

Signature of Parent or Guardian:

Date ________________________

I give permission for my child to leave the Historical Society grounds for a walking tour

of the Academy Hill area.

Name

Although we expect the need will not arise, OUR DISCIPLINE POLICY is as follows:

Respect for one another and the museum at all times is expected of each person on site. If

several reminders of the above rule have been given by the adults in charge and ignored

by the child, parents will be called to pick up their child early. If a child is asked to leave

camp for a behavioral reason, no refund will be issued.

I agree to this rule: ____________________________________________________