CLIFF ROBINSON SUMMER
Height____ Weight _______ Age____
Father's Work No.___________________________________________________________________________
Mother's Work No.___________________________________________________________________________
Emergency Phone No.___________________________________________________________________________
Medical Insurance Company___________________________________________________________________________
St.__________ Zip -____________
Please check appropriate box:
__ June 21 - June 26/ Resident ($150.00 Deposit)
___June 21 - June 26 / Extended Day ($125.00 Deposit)
___June 21 - June 26/ Day ($100.00 Deposit)
Make checks payable to and mail to:
WAIVER AND RELEASE: I understand that any camper who does not abide by the rules and regulations promulgated by the camp is subject to dismissal without reimbursement or recourse. No camper will be allowed to leave the camp grounds for any reason other than a medical emergency until the completion of each camp session.
INSURANCE WAIVER: I hereby authorize the Director of the Cliff Robinson Camp to act for me according to his/her best Judgement in any emergency requiring medical attention. I hereby release and discharge the Cheshire Academy school, the Camp staff, Terry O'Connor, Jim O'Connor, Cliff Robinson, and affiliated entities and their officers, agents and employees from and against any and all liability or causes of actions arising out of or in connection with my participation in the Camp.