Summer 2010 Common Ground Camp Registration

Complete camp descriptions are on our website: www.commongroundct.org.

Important information about the registration process:

Completion of this form will hold your child's space in camp or on the waiting list.

Call (203) 389-4333 ext 1213 or email rholcombe@nhep.com with any questions.

* Required

Child Information

If you are registering more than one camper, you will need to complete a separate registration form for each child.

Child first name *

Child last name *

Date of birth *

age *

Gender *

Female
Male

School *

Child medical information

It is important that we know your child’s medical history in case of an emergency, and so that we can provide your child with the best care. Complete the chart below. Consider allergies to food, medications, and insect stings as well as pollen, etc. Also, indicate if your child has asthma and an inhaler, or other medical conditions we should be aware of.

Medical conditions, symptoms, and treatment example: allergic to strawberries, gets a rash around mouth, tongue swelling, call 911 and administer epipen

Other medical or behavioral information Use this space to tell us anything else about your child that will help us make sure their camp experience is great!

Parent/Guardian information

We will use the information below to contact you about your camp registration, as well as to contact you if needed when your child is at camp.

Parent 1 first name *

Parent 1 last name *

Parent 1 cell phone number *

Parent 1 work phone number

Parent 1 home phone number

Parent 2 first name

Parent 2 last name

Parent 2 cell phone number

Parent 2 work phone number

Email address * We will use this email address to confirm your registration and send you an invoice to pay camp fees online. Please be sure to provide a working address that you check frequently!

Additional email address optional: add another email if you would like us to send information to more than one address

Home address

Street Address *

City *

State *

Zip code *

Emergency contacts

Please list Alternate Emergency Contacts. In an emergency, we will call these people ONLY if we cannot reach you.

Emergency contact name, relationship to child, and phone number(s)