Open Doors Foundation | Opening Minds, Unlocking Hearts, Changing Lives.

March 15-21, 2009
Early Registration deadline January 15, 2009
Registration deadline February 1, 2009

* Indicates required fields.

Camper Information


* Full Name: (Last, First, Middle)

Gender:	Male Female

* Date of Birth:

* Age:

* T-Shirt Size:

* Address: (Street, City, Zip)

* Home Phone:

* E-mail Address:

Parents/Guardian Information


* Full Name: (Last, First, Middle)

* Address: (Street, City, Zip)	If different.

* Home Phone:

* Cell Phone:

* E-mail Address:

* Relationship to Camper:

Miscellaneous Information


Will you be available for a screening interview in February?	No Yes (Daytime) Yes (Evening)

How did you hear about Spring Forward Camp?

Are there any existing medical conditions? Please list

Any allergies? Please list

Is the camper taking any prescription drugs on a regular basis?	Yes - If so, please list below No

I recognize that there are elements of risk in the activities at camp. I give permission for the above named camper to participate in all activities (with exceptions). In the event I cannot be reached in a situation the Camp regards as a medical emergency, I hereby give my Permission to the Camp Personnel to secure proper medical treatment; including but not limited to hospitalization, secure proper treatments, give appropriate examinations, order injections for, administer anesthesia and perform surgery for my child. I have read or will read, and agree to comply to all of the rules and regulations of Camp Summit. I hereby release any staff person, consultant or clinician, Camp Summit, Inc, Academies of Excellence and The Open Door Foundation and its staff and volunteers from any damages for any personal injury or sickness, or otherwise suffered by above camper due to any accident on or off Camp Summit premises while they are staying at Camp Summit.

* Electronic Signature:

Date: