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
OF AN EMERGENCY?

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.

 

 

CONSENT FORM