Please print and mail to us at: PO Box 55-8605 Miami, FL 33255-8605                         
               camp Ñ- Summer 2013 Registration Form

                                                           One application per camper – Application may be duplicated

Camper’s Last Name_______________________First Name__________________________ Age at camp____Birthday_______

Street Address____________________________________________City_________________State______Zip Code________

School______________________________________ Grade (Next Fall)___________ Previous camper? Yes____ No____

Parent’s Last Name________________________ First Name_______________________ Email__________________________

Home Number__________________________ Work Number______________________ Mobile Number__________________

Tell us about your child’s special needs, allergies, and medications.

______________________________________________________________________________________________________

Campers are generally grouped by age.  If you want your camper grouped with another specific camper, please
list the name and the reason for the request.  We reserve the right to place campers where we think they will benefit most.

_____________________________________________________________________________________________________

Emergency Contact Person_____________________ Relationship_______________ Phone ____________________________

Pediatrician_______________________ Phone ____________ Medical Ins. _____________________Policy # _______________

Besides Parents, who else is authorized to pick up your child:

Name________________________________________ Phone ______________________________

As a swimmer my child is:  Above Average____        Average ____     Below Average____       Non-Swimmer____

I give permission to my child to go to the St. Brendan Swimming Pool:  YES____   NO ____  Please initial here:___

T-Shirt Size:(T-Shirts run small)   SMALL (6-8)____     MEDIUM (10-12)____   LARGE (14-16)___   X-LARGE(18-20)___
Mark with an X the appropriate selection:

Session A- 6/10-6/21    Tuition $380 __      Lunch $50 __     AM Care $50__   PM Care $100  ___      Total $_________

Session B-6/24-7/5*      Tuition $342 __   Lunch $45___     AM Care $45__    PM Care $90  ___         Total $_________
*closed July 4th

Session C-7/8-7/19      Tuition $380 __      Lunch $50 __     AM Care $50__   PM Care $100  ___      Total $_________

1 Week –Indicate Wk:____Tuition $200 __    Lunch $25__AM Care $25__     PM Care $
50___     Total $_________

Early Registration Discount: Subtract amount indicated below from the total if application is postmarked by 4/1/2013_____
            1 week $10  -  1 Session $20 - 2 Sessions $30   3 Sessions $40                                       

                                                                     Sibling Discount- Less $20.00 for each additional sibling:_____________

                                                                                                         50% Deposit Due with Registration:_______________

                                                                                                          Amount Due by June 1, 2013:____________________
______________________________________________________________________________________________________


Snack:  Each camper will be provided with a snack daily.

Camp Location:  The camp is located at St. Brendan High School  2950 SW 87th Ave  Miami, FL 33165.

Conduct: Camp Ñ reserves the right to dismiss a camper if their behavior jeopardizes other campers’ safety and well-being.

Field Trips:  Campers will be going on a field trip every Tuesday.  Transportation will be provided by MDCPS licensed buses.  If you
prefer, you may follow the bus in your own car with your child.  Campers must wear their camp t-shirt on all field trips.

Necessary Clothing:  We recommend a T-shirt, shorts, socks and tennis shoes to be worn.  Do not wear open-toed shoes for safety
reasons.  Please label your swimsuit, lunch box, and all personal items.  Camp Ñ will make every reasonable effort to
protect property but will not be responsible for lost items.

Arrival and Pick-Up Time:  All campers in Day Camp and After Care must be picked up on time. If a camper is not picked up
by 3:15 pm he/she will automatically be placed in after care for $10.00 a day.  

Registration Information:  All registration forms received without a 50% deposit will not be considered.  Deposits are non-
refundable.   The  balance of all sessions is due on June 1, 2006.  Space per session is limited.  Registrations will be taken on a
first-come,  first–serve basis.   Mail registration forms along with payment to:
             camp Ñ, Inc.
             PO Box 55-8605
             Miami, FL   33255-8605
             (305)669-6776     
        
I hereby release, and waive my right to make a claim against, Camp Ñ, Inc., St. Brendan High School and their officers and agents
for any liability or damage arising from claims related to the camp activities, including claims for any injury sustained by my child
(ren) while participating in any camp program or event.  I authorize Camp Ñ, Inc. to have my child(ren) treated in the event of an
accident or injury if none of the above contacts can be reached.

I certify that I have read this document and that I understand and agree to all of the foregoing information, terms,
and conditions.

Parent’s/Guardian’s Signature:__________________________________________________________________

Print Name:_________________________________________Date:_________________________

We love to use photos in our promotional material on our website.  If you prefer that we NOT use your child’s image,
please initial here:______