If applying Virtual Program Credit, enter the Virtual Program Credit 19-Digit Account Number
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If applying Virtual Program Credit, enter the Virtual Program Credit CVV Code.
Your answer
If applying Virtual Program Credit, enter the dollar amount of Virtual Program Credit you wish to apply toward your Conestoga Day Camp balance.
Your answer
I will be applying for a grant for camp. *
Allergies (animals, food, insects, medication, etc.) and how to respond to a reaction (if applicable). Please be specific. *
Your answer
Dietary Restrictions, Medications, Physical Limitations or Other Concerns (if applicable).
Please be specific. *
Your answer
Height *
Your answer
Weight *
Your answer
Camp Buddy (if applicable)
Make new friends! Girls are grouped with someone else from their troop if possible, but troops with > three girls are split among units. Please select NO MORE THAN ONE camp buddy.
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Bus Buddy (if applicable)
Your answer
Verify Transportation *
If you are riding the bus, would you consider riding the bus from the other location in order to balance rider distribution?
Clear selection
Overnight *
Camper must be entering 5th grade in the Fall to participate. Indicate whether you will participate in the Thursday overnight
Parent/Guardian Name *
Your answer
Relationship *
Your answer
Parent/Guardian Address
Needed only if different than camper
Your answer
Parent/Guardian Phone *
Your answer
Parent/Guardian Alternate Phone
Your answer
Is this Parent/Guardian an Emergency Contact? *
Emergency Contact #1 Name *
Your answer
Emergency Contact #1 Relationship to Camper *
Your answer
Emergency Contact #1 Daytime Phone *
Your answer
Emergency Contact #1 Evening Phone *
Your answer
Emergency Contact #1 Cell Phone *
Your answer
Emergency Contact #2 Name
Your answer
Emergency Contact #2 Relationship to Camper
Your answer
Emergency Contact #2 Daytime Phone
Your answer
Emergency Contact #2 Evening Phone
Your answer
Emergency Contact #2 Cell Phone
Your answer
Insurance Provider *
Your answer
Insurance Policy Number *
Your answer
Insurance Group Number *
Your answer
I give permission for my daughter to take over-the-counter medication(s) checked according to the manufacturer's instructions and at the dosage appropriate for her weight and/or age: *
Required
Type full name of parent/guardian to electronically "sign" the form. *
Your answer
Enter today's date for confirmation of when health agreement and waiver was acknowledged. *
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YYYY
A copy of your responses will be emailed to the address you provided.