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Houston Sikh Youth Camp 2015 - Winter
Winter 2015 Camp Dates:
Dec 20th to Dec 25th ($210 1
st
child | $190 following child)
REGISTRATION OPENS:
Nov 5th
REGISTRATION DEADLINE
: Dec 15
th
(registration is first come first served and spots may fill up before Dec 15
th
)
Camper's First Name
*
Last Name
*
Gender:
*
Male
Female
Age:
*
Date Of Birth (mm/dd/yy):
*
Grade in school:
*
Number Of Camps Attended in Past:
*
Mother's Name:
*
Father's Name:
*
Address:
*
City:
*
State:
*
Zip:
*
Home Phone:
*
Cell/Alternate Phone
Email Address
Confirm Email
What Musical Instrument Will You Bring?
*
Vaaja
Tabla
None
T-Shirt Size
*
Small (adult)
Medium (adult)
Large (adult)
X-Large (adult)
Small (youth)
Medium (youth)
Large (youth)
Medical Condition/ Physical Disabilities (if any)
Do you take any medicine regularly?
Yes
No
Please list all medicines:
Allergies?
*
Yes
No
Please list any allergies:
Doctor's Name:
Doctor's Phone #:
Medical Insurance:
*
Yes
No
If Yes, Attach a Copy of Insurance
2nd Camper (only complete this section if campers are siblings)
First Name
Last Name
Gender:
Male
Female
Age:
Date Of Birth (mm/dd/yy):
Grade in school:
Number Of Camps Attended in Past:
What Musical Instrument Will You Bring?
Vaaja
Tabla
None
T-Shirt Size
Small (adult)
Medium (adult)
Large (adult)
X-Large (adult)
Small (youth)
Medium (youth)
Large (youth)
Medical Condition/ Physical Disabilities (if any)
Do you take any medicines?
Yes
No
Please list all medications:
Do you have any allergies?
Yes
No
Please list any allergies:
Doctor's Name:
Doctor's Phone #:
Medical Insurance:
Yes
No
If Yes, Attach a Copy of Insurance
3rd Camper (only complete this section if campers are siblings)
First Name
Last Name
Gender:
Male
Female
Age:
Date Of Birth (mm/dd/yy):
Grade in school:
Number Of Camps Attended in Past:
What Musical Instrument Will You Bring?
Vaaja
Tabla
None
T-Shirt Size
Small (adult)
Medium (adult)
Large (adult)
X-Large (adult)
Small (youth)
Medium (youth)
Large (youth)
Medical Condition/ Physical Disabilities (if any)
Do you take any medicines?
Yes
No
Please list all medications:
Do you have any allergies?
Yes
No
Please list any allergies:
Doctor's Name:
Doctor's Phone #:
Medical Insurance:
Yes
No
If Yes, Attach a Copy of Insurance
Electronic Consent and Emergency Contact Information
I, the Undersigned (and my Parent), agree to the following:
I Understand that my failure to maintain such standards or failure to properly participate in camp activities or maintain befitting discipline and conduct may result in suitable and reasonable punishment, including expulsion from the camp, at my expense without any refund of fees paid.
I Hereby waive any and all claims, against the Sikh Center and its volunteers, arising to take whatever action they feel is warranted under the circumstances in regard to my health and safety, including securing medical treatment (at my own or my parent’s expense). I further release any of these persons from any liability for such decisions or actions, which may be taken on my behalf
I understand that I must respect the facility and leave it in the way I found it at the beginning of the camp. I will be liable to pay a fee as set forth by the organizers if I, or any of my roommates bring any damage to the room or facility that I am using. All of the campers in each room are all responsible for that room. The damages fee will divided among all of the camper in that particular room in question.
Must pay at least $150 before being officially registered. If cancellation occurs after Dec 15
th
no refunds will be offered. Before Dec 8
th
50% of the registration fee will be returned.
During the stay at Houston Sikh Youth Camp, various volunteer doctors will
be assisting my child(ren) with various minor ailments. I have fully
disclosed all relevant allergies or medical conditions to the Houston Sikh
Youth Camp. I will not hold the doctors professionally or personally
liable for the administration of medicine or any health care during the
duration of the camp.
Electronic Consent: Parent/Guardian
*
Yes
No
In Case of an Emergency, Contact:
*
Phone #:
*
Payment Information
Pay with: (Checks Payable to 'Sikh Center')
Please note: If paying with check or cash, your registration is not confirmed until payment is submitted. Also, if you are paying with cash, select 'Pay by check' on the next page to finish your registration.
*
Cash
Check
PayPal (Please follow link for payment on next page after you click submit)
For Paypal Payment, please complete the following: Number of Campers: 1st Camper $210.00, each additional Camper: $190.00
*
One Camper
Two Campers
Three Campers
Current Total:
$0.00
Calculate
Any additional notes/comments regarding registration?
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