Randall Davey Audubon Center 2008 Summer Day Camp Registration * An asterisk means the field is required. REGISTRANT INFORMATION * Camper's First Name * __________________________________ * Camper's Last Name * ___________________________________ * Camper's Age *__________________________________________ * Parents/Guardians Name(s) *_____________________________ * Address *_______________________________________________ * City *__________________________________________________ * State *_________________________________________________ * Zip Code *______________________________________________ * E-mail * _______________________________________________ * Home Phone *____________________________________________ Work Phone______________________________________________ Cell Phone______________________________________________ CAMP FEE INFORMATION Please register for camps below. Snakes, Bats, and Wolves Camp AGES: Post K-7 YEARS July 7-11, 2008 ___ $225.00 RDAC Member Fee ___ $250.00 Non-Member Fee Nature Exploration Camp AGES: Post K-7 YEARS July 28-August 1, 2008 ___ $225.00 RDAC Member Fee ___ $250.00 Non-Member Fee Powerful Pollinators Camp AGES: 7-9 YEARS June 16-20, 2008 ___ $225.00 RDAC Member Fee ___ $250.00 Non-Member Fee Wild Hunters AGES: 7-9 YEARS July 14-18, 2008 ___ $225.00 RDAC Member Fee ___ $250.00 Non-Member Fee No-Waste Camp Challenge AGES: 7-9 YEARS August 4-8, 2008 ___ $225.00 RDAC Member Fee ___ $250.00 Non-Member Fee Birds. Butterflies. Bats, and Bees AGES: 9-11 YEARS June 23-27, 2008 ___ $225.00 RDAC Member Fee ___ $250.00 Non-Member Fee Wildlife Explorers AGES: 9-11 YEARS July 21-25, 2008 ___ $225.00 RDAC Member Fee ___ $250.00 Non-Member Fee Widerness Discovery OVERNIGHT NOTE: Only campers registered for the Wilderness Discovery Camp (Ages 9-11 years) can sign up for this program which is from July 25 (7:30pm)-26 (9:00am), 2008. ___ $40.00 Pre-Care (8-9AM): $6/day After-Care (3:30-5PM): $9/day ADDITIONAL INFORMATION Emergency Contact Information Please provide the names and phone numbers of two reliable contacts in the even you cannot be reached. * Emergency Contact's Name *__________________________________________ * Emergency Contact's Phone *_________________________________________ * Emergency Contact's Name *__________________________________________ * Emergency Contact's Phone *_________________________________________ Health and Wellness History Please check all that apply to your child. ___ ADD/ADHD ___ Asthma ___ Brittle Bones ___ Bleeding Disorder ___ Convulsions ___ Diabetes ___ Ear Infections ___ Heart Defect/Disease ___ Speech/Language Problems Health and Wellness Information Is there any other health information about your child you would like to provide? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ___ Does your child have any food allergies? What______________________________________________________________ * Family Physician's Name ____________________________________________ * Family Physician's Phone ___________________________________________ Additional Information Is there anything else you would like our staff to know about your child (e.g., shyness, a strong interest in reptiles, etc.)? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ CAMPER RELEASE AUTHORIZATION If you would like adults other than yourself to pick-up your children, please list their names below. NO CHILD WILL BE RELEASED TO ANY ADULT OTHER THAN THE PARENTS/GUARDIANS IF WE DO NOT HAVE THIS INFORMATION ON FILE AT THE TIME OF PICK-UP. The following people are authorized to pick-up my child: Name ___________________________________________ Name ___________________________________________ Name ___________________________________________ Name ___________________________________________ PAYMENT INSTRUCTIONS Visa/MC Number ____________________________ Expiration Date _________ or Check Please make checks payable to RDAC. Audubon Summer Day Camp must receive checks two weeks from today or camp slots will be forfeited. REFUND POLICY CANCELLATIONS MUST BE IN WRITING! If cancellations are received at least 3 weeks prior to the scheduled camp session, tuition less a non-refundable $25 administrative fee will be refunded. NO REFUNDS WILL BE ISSUED FOR CANCELLATIONS WITHIN 3 WEEKS OF SCHEDULED CAMPS. DISCLAIMER All health information is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities as noted by me. If I cannot be reached in the case of an emergency, I hereby give permission to the physician selected by the Audubon staff to hospitalize, secure proper treatment for, and to order injections and/or anesthesia and/or surgery for my child as named above. I hereby release National Audubon Society, their agents, and employees from any and all claims of any kind, for damages or injuries received by my child while participating in activities at the Audubon Summer Day Camp at the Randall Davey Audubon Center. Unless I give written notice to the contrary, I give consent to pictures of my child performing Audubon Summer Day Camp activities being used in future Audubon New Mexico marketing and promotional materials. * ___ I Agree with the above Disclaimer Deliver to: 1800 Upper Canyon Road Santa Fe, New Mexico Mail to: Audubon Camp PO Box 9314 Santa Fe, NM 87504-9314 Fax to: (505) 983-2505 e-mail to: audubonnmedu@audubon.org 3/16/08