Goes by: _____________   Fall '08: Grade ___ School _____________________________________

Parent/Guardian's Name  _________________________________________

Mailing Adr  ________________________________________________________

City  _____________________________  St ____ Zip &+4  _____________

Day phone__________________ Eve _________________ Cell _________________

e-mail  _______________________________  _______________________________

Weeks Camper will attend:   ___ July 21-25 ___ July 28-Aug 1; ___ Aug 4-11; ___ Aug 11-15

My child will be dropped off by:__________________ picked up by: __________________

Allergies/Medical concerns :________________________________________________

Other needs or concerns: ___________________________________________________

My child can ___ cannot ___ participate in physical activities.

I hereby release The Peace Center, Newtown Friends Meeting, volunteers and staff working for these groups from any and all liability for injury or illness that my child may sustain or contract, during this camp. In the event of an emergency, if I cannot be reached, I hereby authorize an adult leader of the Peace Camp as agent for me, to consent to any x-ray or examination, and any medical, dental or surgical treatment required to treat my child for that emergency; including but not limited to hospital care as recommended and supervised by a duly licensed physician, surgeon or dentist (as appropriate) either at a doctor's office or in any hospital or other licensed medical facility.
In the case of such an emergency, I expect to be contacted as soon as possible at ________________

If I cannot be reached, I authorize (name) ___________________ (relationship) ________________

as an emergency contact to be reached at _________________

Print Name: __________________ Signature : _______________________ Date: ______

I give my permission for my child to be photographed for publicity by news media and The Peace Center.

Parent/ Guardian Signature : _______________________ Date: ______

 The Peace Center

for a total of $ _______

Name on card ______________________________ exp ___/___

Address: same / or ______________________________________________