418 4th Street • Marietta, Ohio 45750 • 740.373.4180
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The Castle’s History Camp Registration Form- 2024
The Castle
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The Castle’s History Camp Registration Form- 2024
The Castle’s History Camp Registration Form
The Castle’s History Camp
Step
1
of
2
50%
July 8-12, 2024 9am-3pm
Enrollment in History Camp at The Castle is for students entering the third through sixth grades in the fall of 2024. The registration fee of $30.00 per day per camper or $125.00 per week per camper covers the cost of all the materials and field trips. As part of the registration process, please fill out the Emergency Medical Authorization and the Photo Release Form, which are included. Camp size is limited to 30 campers on a first come first served basis. Early registration is encouraged. Please return registration papers along with payment by 4pm June 21, 2024 to The Castle.
Camper's Name:
(Required)
First
Last
Mailing Address:
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone (Best to reach you):
(Required)
Parent/Guardian Email:
(Required)
Age:
(Required)
Grade Entering:
(Required)
Name of School:
(Required)
Please enroll me for the following camp days ($30.00 per day or $125 per week):
Monday, July 8
Tuesday, July 9
Wednesday, July 10
Thursday, July 11
Friday, July 12
All week, July 8 – 12
Please make checks payable to: The Castle, 418 Fourth St., Marietta, OH 45750 For more information call The Castle at (740) 373-4180
In the event of an emergency, The Castle contacts emergency services, and then the primary and secondary contacts listed on this form. This form will be provided to emergency service personnel.
Emergency Medical Authorization
Camper‘s Name:
(Required)
First
Last
Primary Emergency Contact Name:
(Required)
First
Last
Home Phone:
Cell Phone:
(Required)
Work Phone:
Secondary Emergency Contact Name:
(Required)
First
Last
Home Phone:
Cell Phone:
(Required)
Work Phone:
Medical History
Allergies (Food, Pollen, Etc):
(Required)
Food Preferences (Vegetarian, Vegan, Etc.):
Medications Being Taken:
(Required)
Tell us a little about you/your camper:
My camper/I use(s) a wheelchair, crutches, walker or another mobility aid
My camper/I might be sensory sensitive
My camper/I has (have) vision loss
My camper/I is (am) deaf or hard-of-hearing
My camper/I has (have) an intellectual disability
Please elaborate on any boxes marked:
Is there anything else you wish for us to know about your camper?
Part I: To Grant Consent
I hereby give consent for the following medical care providers and local hospital to be called.
Doctor:
(Required)
First
Last
Phone:
(Required)
Dentist:
(Required)
First
Last
Phone:
(Required)
Medical Specialist:
First
Last
Phone:
Local Hospital:
First
Last
Phone:
Can we administrator first aid?
(Required)
Yes
No
In the event, reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the above-named doctor, or in the event that the designated practitioner is not available, by another licensed physician or dentist, and (2) the transfer of the camper to any hospital reasonably accessible.
Date:
MM slash DD slash YYYY
Signature of Parent or Guardian:
Part II: Refusal to Consent
I do NOT give my consent for emergency medical treatment of my camper. In the event of illness or injury requiring emergency treatment, I wish The Castle authorities to take the following action:
Date:
MM slash DD slash YYYY
Signature of Parent or Guardian:
Permission to Use Photograph:
Consent
I grant to The Castle, its representatives and employees the right to take photographs of my camper in connection with the above-identified event. I agree that The Castle may use such photographs of my camper with or without their name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, web content, and social media.
Consent
I do NOT grant to The Castle, its representatives and employees the right to take photographs of my camper in connection with the above-identified event.
I have read and understand the above:
Parent/Guardian Signature:
(Required)
Printed Parent/Guardian Name:
First
Last
Date:
MM slash DD slash YYYY
Phone Number:
Need Financial Aid?
Click Here to Download Our Application!
Registration Fees:
I intend to pay by:
(Required)
Online payment
Check in the mail
Financial aid request
Registering for:
(Required)
Week
Day/Days
Registration fee per camper per day:
Quantity
Price:
$30.00
Quantity
(Enter number of days under Quantity)
Registration fee per camper per week:
Price:
Credit Card
Cardholder Name
Card Details
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The Castle’s History Camp Registration Form- 2024
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