Camper Registration 2017 Acceptance of Camp Behavior Policy & Anti-Bullying AgreementCode of Conduct Agreement* By checking here, I am stating that I have read and agree to abide by, all policies contained with the anti-bullying policy and behavior agreement. Furthermore, I certify that I have discussed all the policies, and their meanings and consequences, with my child(ren). Camper detailsName* First Last Gender*MaleFemaleAge*Birthdate* Grade completed*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Enter Email Confirm Email Parent InfoParent or Guardian names*Parent Phone (Home)*Parent Phone (Cell)*Parent Phone (Work)*Parent Email* Enter Email Confirm Email Getting to CampWho will BRING Camper TO camp?*Who will PICK UP Camper FROM camp?*Emergency contactPlease list name, contact info (home, work and cell) and relationship for person to contact if Parent or Guardian above cannot be reached.Emergency Contact Name* First Last Relationship*Emergency Contact Phone*Emergency Contact Phone (Cell)*At campT-shirt size*Note: These are adult sizes!X-SmallSmallMediumLargeXLXXLHow good is your Danish?*BeginnerIntermediateFluentHow many years have you been to camp?*This is my....First yearSecond yearThird yearFourth yearFifth yearSixth yearSeventh yearEighth year !!!Where did you hear about camp?*It's OK to mark more than one. Internet BIEN DBIA DSS Danish Pioneer ScanFair Northwest Danish Association Flier I have always known about Camp. Doesn't everyone? None of the above Camper Health InformationPresent medication(s)*Camper must bring medications to camp and turn into Camp NurseNOTE: If none, please write NONE. Physical, behavioral, or emotional concerns*Please list concerns that staff should know about. NOTE: If none, please write NONE. Allergies, including to medications & severe food allergies*NOTE: If none, please write NONEHealth Insurance & Family DoctorHealth insurance provider*Group number*ID Number*Name of primary person insured*Insurance provider phone number*Family doctor practice nameFamily doctor cityFamily doctor phone number*Date of last tetanus shot/booster* Special PermissionsPhotography*I grant the right to photograph my child and use the photo reproduction of his/her physical likeness for publication processes, whether electronic, print, digital or electronic publishing via the internet.I agreeI disagreeNon-prescription pain medication*I grant the right for Staff to give my child non-prescription pain reliever, if needed. I agreeI disagreeThe Northwest Danish Association Newsletter We'd like to subscribe! (parent or person filling in this form) Camp FeesCamp Tuition*Sorry Early Bird pricing ended March 31st. Please remember, to qualify for the NWDA membership price, the camper or the parent must be a current NWDA member (sorry, grandparent memberships don't qualify for the membership discount). After March 31st 2017, regular tuition prices apply: Regular NWDA Member - $725.00 Regular Non-NWDA Member - $800.00NWDA Member - $725Non-NWDA Member - $800Optional Requests Bedding provided by Menucha Special diet request Payment Method*Please be sure to send in your payment as soon as possible after filling in this form. We will not be sending an invoice. Thank you.Credit cardCheckTotal $0.00 Almost there! Just two more stepsAfter you click Submit below, you will be redirected to the Medical Waiver for your signature using our Electronic eSignature. After you've signed, you'll get details on how to make your payment and how to complete your special diet request (if selected).