CAMP LAUGHING LOON 2010 DAY CAMP REGISTRATION
RETURN APPLICATION WITH CHECK TO: COMPLETE CAMPERSHIP APPLICATION
CAMP LAUGHING LOON TO OBTAIN FINANCIAL AID INFORMATION
PO BOX 201
EAST WATERBORO, ME 04030 REGISTRATION PROCESSED & POSTCARD SENT ________
PHONE: 247-6329 FAX: 247-6339
NAME OF CHILD: ___________________________________________________________________ DOB: ___________ AGE ________ SEX M F
PARENT/GUARDIAN NAME: _____________________________________________________________ Grade Entering Fall 2009 ______________
ADDRESS:___________________________________________________ TEL # Home: _____________ Work: __________ Cell: __________
CITY:___________________________________ ZIP: __________ Has your child attended CLL in the past? Y N
MAILING ADDRESS IF NOT THE SAME AS ABOVE:_____________________________________________________________
EMAIL ADDRESS: _______________________________________________________________________________________
**Required** EMERGENCY TEL & NAME (OTHER THAN HOME): ____________________________________________________________
NAME OF HEALTH INSURANCE COMPANY: ____________________________________ POLICY #: ____________________
Does your child have any physical restrictions, health problems, current medical conditions, disabilities or impairments? Yes No
If yes, please specify: ___________________________________________________________________________________________
Does your child have an IEP or 504 in place at school? Yes No
Will the above condition(s) require any additional support service(s) from our staff? Yes No
If yes, please explain: ___________________________________________________________________________________________
Is your child currently taking any medications? Yes No List all Medications:______________________________________________
Will your child be required to take any medication during the camp day? Yes No
If yes, please complete the enclosed medical release form. This form must be returned 7-days prior to your child attending camp or
an alternate week will need to be scheduled. (A doctors note is required in order for our camp directors to administer medication(s) to your child.)
Does your child have any known allergies? Yes No
If yes, please explain: ___________________________________________________________________________________________
CLL will attempt to make reasonable accommodations for children with disabilities. Each application will be assessed on a case by case basis.
Reminder: Days/Weeks Cannot be Changed
CHECK OFF WEEK(S) AND CIRCLE DAYS ATTENDING PLEASE INDICATE TRANSPORTATION NEEDS
___Mardens Parking Lot -Biddeford 8:10 am / 4:50 pm ___Burns School - Saco 8:25 am / 4:30 pm ___Dayton Elem. School 8:45 am / 4:15 pm
______ JUNE 28 - JULY 2 M T W TH F _____ JULY 5 - JULY 9 M T W TH F ______ JULY 12 - JULY 16 M T W TH F _____JULY 19 -JULY 23 M T W TH F ______ JULY 26 - JULY 30 M T W TH F ______ AUG 2 - AUG 6 M T W TH F ______ AUG 9 - AUG 13 M T W TH F _____ AUG 16-AUG 20 M T W TH F
You may have my permission to use my child's photo for promotional purposes, . YES NO I have read and understand the Disciplinary Code & Transportation Policy AND the Cancellations/Refunds Policy included in this registration packet
SIGNATURE OF PARENT/GUARDIAN: ________________________________________SIGNATURE OF PARENT/GUARDIAN:________________________________
click here to review the disciplinary code
