DEAF YOUTH CAMP OF WV, INC.
311 James Street
Bridgeport, WV 26330
APPLICATION FORM
| Camper Ages: 6-14 | Counselor-in-Training Ages: 15-20 Counselor Ages: 21+ |
TO BE FILLED OUT BY THE CAMPER'S PARENTS OR LEGAL GUARDIAN
| CAMPERS NAME ____________________________ NICKNAME _________________ |
| AGE ____________ DATE OF BIRTH _________________________ MALE OR FEMALE |
| ADDRESS/ZIP____________________________________________________________ |
| TELEPHONE NUMBER ( )_____________________ COUNTY _________________ |
| PARENT OR LEGAL GUARDIAN'S NAME ____________________________________ |
| ADDRESS/ZIP ____________________________________________________________ |
| HOME PHONE ________________________ WORK PHONE _____________________ |
IF PARENT OR GUARDIAN CANNOT BE REACHED, WHO
SHOULD WE NOTIFY IN CASE |
| NAME __________________________________ RELATIONSHIP _________________ |
| PHONE NUMBER ________________________________________________________ |
| PICK-UP AUTHORIZATION |
| I hereby authorize |
| 1. ______________________________________________________________________ NAME PHONE# RELATIONSHIP |
| 2. ______________________________________________________________________ NAME PHONE# RELATIONSHIP |
| 3. ______________________________________________________________________ NAME PHONE# RELATIONSHIP |
| to pick up my child from Deaf Camp. If there are any changes in the
arrangements, I will give written notice to the Camp Director. (NOTE: If there
are any special instructions, or any persons who are NEVER to be authorized to pick up
your child, please indicate below.
|