Mother Daughter Weekend Registration
We can't wait for you to join us for our 2021 Mother Daughter Weekends!  Please choose between two weekends, the first beginning Friday, May 14 through Sunday, May 16, 2021 and the second beginning Friday, May 21st through Sunday, May 23rd, 2021.  To help with your travel plans, Friday afternoon will kick off around 4:30pm and Sunday will conclude with lunch.

Tuition is $650 for mom and one daughter.  Each additional daughter is $200.  Your tuition includes all meals, snacks, accommodations, and program activities.  Your spot will be secured upon completion of this application and the receipt of a $250 deposit.  Remaining tuition is due May 1st.

If you are applying after May 1st, we ask for payment in full.  Full refunds will be provided for any cancellations before May 1st, 2021.  If it is not recommended to proceed with Mother Daughter Weekend 2021 due to current health recommendations, families can choose to roll their payments to Mother Daughter Weekend 2022 or receive a full refund.  

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Weekend Preference *
Mother First Name *
Mother Last Name
Mother Date of Birth *
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Mailing Address (including city, state and zip) *
Email *
Phone Number *
Mother's Shirt Size *
Daughter One First and Last Name *
Daughter One Grade *
Daughter One Date of Birth *
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Daughter Two First and Last Name (please skip if only one daughter)
Daughter Two Grade
Daughter Two Date of Birth
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Daughter Three First and Last Name
Daughter Three Grade
Daughter Three Date of Birth
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Currently enrolled session if your daughter(s) will be joining us at Keystone for summer 2021 *
Daughter One Shirt Size *
Daughter Two Shirt Size
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Daughter Three Shirt Size
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Tuition Charge *
If your daughter is over 60 lbs, are you interested in Zip Lining over the weekend? *
Total number of family members planning on Zip Lining over the weekend? *
Are you interested in Horseback Riding over the weekend? *
Total number of family members planning on Horseback Riding over the weekend? *
Do you have a bunk request (other families you would like to share a cabin with)? *
Please list any food allergies or dietary needs for you and your family this weekend. Please list the type of allergic reaction that is associated with the allergy (anaphylactic, gastrointestinal symptoms, etc) : *
We will email you an invoice for your tuition through PayPal.  Please note your spot isn't confirmed until we receive payment.  Please enter your PayPal email address below.  We can also accept checks at 101 Keystone Camp Rd, Brevard, NC 28712. *
Mother Daughter Health Information
Welcome to Mother Daughter weekend!  We are so excited you’ve trusted us to share this wonderful experience with your family.  As part of our registration process, we ask you to list any current medications, both prescribed and over-the-counter, for both you and your daughter(s).  We also ask you to update us on any known allergies or health conditions requiring treatment, restriction, or other accommodations while on site.  This information is required for participation.  Anything you share with us will be held in the strictest of confidence and only used for your health and safety.  If you have any questions, please feel free to contact the office at (828) 884-9125 or office@keystonecamp.  Thank you!

Please list the names and dosage of any current over-the-counter or prescription medications you are currently taking (enter N/A if none): *
Please list the names and dosage of any current over-the-counter or prescription medications your daughter(s) are taking.  If more than one daughter is attending, please let us know who is taking which medicine (enter N/A/ if none). *
Please list the names and known allergies for any person in your group (enter N/A if none). Please also indicate the type of reaction that is associated with the allergy (anaphylactic, nasal congestion, gastrointestinal symptoms, etc.): *
Please list any health conditions we should be aware of (enter N/A if none): *
Name and Phone Number of Emergency Contact 1 *
Name and Phone Number of Emergency Contact 2 *
This health history is correct and complete as far as I know. The persons herein named have permission to engage in all camp activities except as noted. It is my intention that the camp be treated as acting in loco parentis if the person herein named is a minor. Further, it is my intention that the appropriate representatives of the camp be treated as “personal representatives”for the purposes of disclosing protected health information pursuant to the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996. I hereby agree (pursuant to 45 CFR § 164.510(b)) to the disclosure to camp representatives of the protected health information of the person herein described, as necessary: (i) to provide relevant information to the camp representatives related to the person’s ability to participate in camp activities; and(ii) in the case of minors, to provide relevant information to the camp representatives to keep me informed of my child’s health status. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out of camp. I understand that part of the Camp experience involves activities and group living arrangements and interactions that may be new to my child, and that they come with certain risks and uncertainties beyond what my child may be used to dealing with at home. I am aware of these risks, and I am assuming them on behalf of my child. I realize that no environment is risk-free, and so I have instructed my child on the importance of abiding by the Camp’s rules, and my child and I both agree that he or she is familiar with these rules and will obey them. I hereby give permission to the camp to provide, seek, and consent to routine health care, administration of prescribed medications, and emergency treatment for me/my child, as may be necessary, including, but not limited to x-rays, routine tests and treatment, and/or hospitalization. I also give permission for the camp to arrange related transportation. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. *
Required
RELEASE/CONSENT/ACKNOWLEDGMENT ASSUMPTION OF RISK                                                     By my execution of the application, I acknowledge that I have given Keystone Camp full disclosure of any pre-existing physical or mental defects, challenges or problems, which I or my camper may have. I further acknowledge that I am aware of the types of activities which I and my camper will be participating in during our attendance at Keystone Camp on or off the premises of said camp and the inherent dangers related thereto, including but not limited to swimming, canoeing, hiking, backpacking, camping, rock climbing, high ropes, zip line, horseback riding, gymnastics, and athletic events. Keystone Camp cannot be responsible for the consequence of the failure of myself or my camper to obey employees and to abide by the rules and regulations established by the Camp, or from incidences involving my or my camper’s negligence.I also acknowledge that I have been given ample opportunity to ask any question which we may have about the environment in which we will live and the activities in which we will participate.If outside medical services (x-rays, lab tests, etc.) should be needed we understand that we are financially responsible.I give permission for photographs or video footage of my daughter to be used by the Camp for promotional purposes. I also grant permission for Keystone to use my comments and testimonials in promotional materials.  By checking "I Agree" below I understand this is binding and constitutes my legal signature.   *
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