Stunt Camp at Stunt Ranch Enrollment Form - Page 1 of 3
This form can be used to register up to four children with the same parent/guardian.
Fields marked with an * are required fields.
* Parent / Guardian Name:
* Address:

* Phone Numbers: (home)
(work)
(cell)
* E-mail Address:
* Emergency Contact:
* Emergency Contact Relationship:
* Emergency Contact Phone Numbers: (home)
(work)
(cell)
* Are you interested in joining a carpool?
* Are you interested in flexible pick up/drop off times?
Child #1
Child's Name:
Grade:
Does your child have any medical conditions we should be aware of?
If so, please describe:
Medical Provider Name:
Medical Provider Phone Number:
Does your child have any medication that will need to be taken during camp?
Prescription #1 Name:
Prescription #1 Dosage:
Prescription #1 Instructions:
Prescription #2 Name:
Prescription #2 Dosage:
Prescription #2 Instructions:
Child #2
Child's Name:
Grade:
Does your child have any medical conditions we should be aware of?
If so, please describe:
Medical Provider Name:
Medical Provider Phone Number:
Does your child have any medication that will need to be taken during camp?
Prescription #1 Name:
Prescription #1 Dosage:
Prescription #1 Instructions:
Prescription #2 Name:
Prescription #2 Dosage:
Prescription #2 Instructions:
Child #3
Child's Name:
Grade:
Does your child have any medical conditions we should be aware of?
If so, please describe:
Medical Provider Name:
Medical Provider Phone Number:
Does your child have any medication that will need to be taken during camp?
Prescription #1 Name:
Prescription #1 Dosage:
Prescription #1 Instructions:
Prescription #2 Name:
Prescription #2 Dosage:
Prescription #2 Instructions:
Child #4
Child's Name:
Grade:
Does your child have any medical conditions we should be aware of?
If so, please describe:
Medical Provider Name:
Medical Provider Phone Number:
Does your child have any medication that will need to be taken during camp?
Prescription #1 Name:
Prescription #1 Dosage:
Prescription #1 Instructions:
Prescription #2 Name:
Prescription #2 Dosage:
Prescription #2 Instructions:
Will you be dropping off and picking up your child/children every day?
If not, please list those people who are authorized to transport your child/children:
(your spouse or any other authorized relatives should be listed)
Name:
Phone:
Relationship:
Name:
Phone:
Relationship:
Name:
Phone:
Relationship:
Please note that the people listed above will need to present valid identification at time of pickup.