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Town of Beech Mountain
2015 Summer Adventure Camp Registration
PERSONAL INFORMATION
Camper’s Name_______________________________________________________________ Sex____ Age_____ Date of Birth___/___/___
Camper’s Name_______________________________________________________________ Sex____ Age_____ Date of Birth___/___/___
Parent/Guardian___________________________________________________________________________________________________________
Address_____________________________________________________________________________________________________________________
H. Phone_______________________ W. Phone_____________________ C. Phone___________________ Email________________________
EMERGENCY CALL LIST
Name____________________________________ Relation_______________________________ Phone__________________________________
Name____________________________________ Relation_______________________________ Phone__________________________________
CAMP SELECTION: select appropriate date(s) and insert appropriate fee(s).
For us to better assist you and your camper, we require a 24 hour notice before attending date.
Week 1: June 22rd – June 26th 9am-3pm
Week 2: June 29th – July 3rd 9am-3pm
Week 3: July 6th – July 10th 9am-3pm
Week 4: July 13th – July 17th 9am-3pm
Week 5: July 20th – July 24th 9am-3pm
Week 6: July 27th - July 31st 9am-3pm
$125.00 Week _______
$125.00 Week _______
$125.00 Week _______
$125.00 Week _______
$125.00 Week _______
$125.00 Week _______
Week 1: June 22rd – June 26th 9am-3pm
Week 2: June 29th – July 3rd 9am-3pm
Week 3: July 6th – July 10th 9am-3pm
Week 4: July 13th – July 17th 9am-3pm
Week 5: July 20st – July 24th 9am-3pm
Week 6: July 27th - July 31st 9am-3pm
$50.00
$50.00
$50.00
$50.00
$50.00
$50.00
B.E.S.T. Program – Campers 13 – 16 years of age
$30 Individual Day _________
$30 Individual Day _________
$30 Individual Day _________
$30 Individual Day _________
$30 Individual Day _________
$30 Individual Day _________
Total__________
Total__________
Total__________
Total__________
Total__________
Total__________
Total____________________________________________________
Total____________________________________________________
Total____________________________________________________
Total____________________________________________________
Total____________________________________________________
Total____________________________________________________
I agree that photographs of the participant may be published for the purpose of publicizing or promoting
programs operated and/or sponsored by the Town of Beech Mountain.
Parent/Guardian ______________________________________________________________________________ Date ______/______/_______
Town of Beech Mountain
2015 Summer Adventure Camp Health Information
CAMPER’S NAME: _________________________________________________________________________________________________________
Any Hospitalization? Any Serious Illness? Any Physical Disabilities? Any Special Needs?
Any Behavioral Concerns? How might these affect your child’s participation?
______________________________________________________________________________________________________________________________
Any Special Accommodations Needed? _________________________________________________________________________________
______________________________________________________________________________________________________________________________
Any Allergies? _____________________________________________________________________________________________________________
Complete this box if participant will be taking medication, including Epi-pens and inhalers during camp hours:
MEDICATIONS SHOULD BE LABLED AND GIVEN TO STAFF FOR SAFETY REASONS. THE CHILD MUST BE AWARE
OF NOT ONLY THE DOSAGE BUT WHEN THEY NEED TO TAKE IT.
Name of Medications: _____________________________________________________________________________________________________
Reason for Medications: ___________________________________ Medications Dose: __________________________________________
Directions for Medications: _______________________________________________________________________________________________
Family Physician Name:___________________________________________________________________________________________________
Phone: ___________________________________ City:________________________________ State:______________________________________
CAMPER’S NAME: _________________________________________________________________________________________________________
Any Hospitalization? Any Serious Illness? Any Physical Disabilities? Any Special Needs?
Any Behavioral Concerns? How might these affect your child’s participation?
______________________________________________________________________________________________________________________________
Any Special Accommodations Needed? _________________________________________________________________________________
______________________________________________________________________________________________________________________________
Any Allergies? _____________________________________________________________________________________________________________
Complete this box if participant will be taking medication, including Epi-pens and inhalers during camp hours:
MEDICATIONS SHOULD BE LABLED AND GIVEN TO STAFF FOR SAFETY REASONS. THE CHILD MUST BE AWARE
OF NOT ONLY THE DOSAGE BUT WHEN THEY NEED TO TAKE IT.
Name of Medications: _____________________________________________________________________________________________________
Reason for Medications: ___________________________________ Medications Dose: __________________________________________
Directions for Medications: _______________________________________________________________________________________________
Family Physician Name:___________________________________________________________________________________________________
Phone: ___________________________________ City:________________________________ State:______________________________________
Camp Facts
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Town of Beech Mountain
2015 Summer Adventure Camp Information
All refund requests must be received by the Wednesday before the week of camp!
Mail applications to Buckeye Recreation Center, 1330 Pine Ridge Road, Beech Mountain, NC 28604.
Summer Adventure Camp Series runs from 9:00 a.m.-3:00 p.m.
Some Summer Adventure Camp Field Trips will cause camp to run pass the allotted camp end time
(3:00 p.m.); If this is the case, the Summer Camp Director will notify the Buckeye Recreation Center
of the expected arrival time so the Recreation Staff can notify the parents.
The Summer Adventure Camp Series is offered to ages 5-12
There will be an after camp program for the charge of $10 per child from 3:00 p.m. – 5:00 p.m.
(Must be signed up before that day)
A $10 late fee for any camper not picked up by 3:15
Discipline
Due to the importance of safety in our day camp program, the staff reserves the right to discipline any
and all campers who display inappropriate or unsafe behavior. The following is our discipline policy:
1.
2.
3.
4.
Verbal warning.
Time out of activity (including, but not limited to swimming and field trips).
Parent/guardian called.
If child continues to misbehave, the camper will be dismissed from camp, and no refunds will be
given.
*The Summer Camp Director and/or the Park and Recreation Director
reserve the right to dismiss individuals from camp.*
For detailed itinerary of activities please click on: Summer Camp Schedule
Buckeye Recreation Center
Town of Beech Mountain
1330 Pine Ridge Road
Beech Mountain, NC 28604
828-387-3003