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Houston Sikh Youth Camp - Winter 2016
Winter 2016 camp dates:
Thu Dec 22
nd
- Tue Dec 27
th
Registration dates:
Tue Nov 1
st
- Thu Dec 15
th
*Note: Registration is first come first served and spots may fill up before Dec 15
th
How many siblings are you registering?
*
1 camper $210
2 campers $400
3 campers $590
1st Sibling
Camper Information
Full Name
*
Gender
*
Male
Female
Date of Birth
*
+
Grade in school
*
1
2
3
4
5
6
7
8
9
10
11
12
College freshman
College sophomore
Other
Number of Camps Attended in the Past
*
0
1-2
3-5
6+
What Musical Instrument Will You Bring?
Vaaja
Tabla
Other
Other
T-Shirt Size
*
Small (adult)
Medium (adult)
Large (adult)
X-Large (adult)
Small (youth)
Medium (youth)
Large (youth)
Camper Medical Information
Medical Condition/ Physical Disabilities (if any)
0/255 characters
Do you take any medicine regularly?
*
Yes
No
Please list medications
0/255 characters
Allergies?
*
Yes
No
Please list allergies
Doctor's Name
Doctor's Phone Number
Has medical insurance?
*
Yes
No
Please attach a copy of insurance
2nd Sibling
Full Name
Gender
Male
Female
Date of Birth
+
Grade in school
1
2
3
4
5
6
7
8
9
10
11
12
College freshman
College sophomore
Other
Number of Camps Attended in the Past
0
1-2
3-5
6+
What Musical Instrument Will You Bring?
Vaaja
Tabla
Other
Other
T-Shirt Size
Small (adult)
Medium (adult)
Large (adult)
X-Large (adult)
Small (youth)
Medium (youth)
Large (youth)
Camper Medical Information
Medical Condition/ Physical Disabilities (if any)
0/255 characters
Do you take any medicine regularly?
Yes
No
Please list medications
0/255 characters
Allergies?
Yes
No
Please list allergies
Doctor's Name
Doctor's Phone Number
Has medical insurance?
Yes
No
Please attach a copy of insurance
3rd Sibling
Full Name
Gender
Male
Female
Date of Birth
+
Grade in school
1
2
3
4
5
6
7
8
9
10
11
12
College freshman
College sophomore
Other
Number of Camps Attended in the Past
0
1-2
3-5
6+
What Musical Instrument Will You Bring?
Vaaja
Tabla
Other
Other
T-Shirt Size
Small (adult)
Medium (adult)
Large (adult)
X-Large (adult)
Small (youth)
Medium (youth)
Large (youth)
Camper Medical Information
Medical Condition/ Physical Disabilities (if any)
0/255 characters
Do you take any medicine regularly?
Yes
No
Please list medications
0/255 characters
Allergies?
Yes
No
Please list allergies
Doctor's Name
Doctor's Phone Number
Has medical insurance?
Yes
No
Please attach a copy of insurance
Parent/Guardian Information
Full Name
*
Relationship to child(ren)
*
Full Name
Relationship to child(ren)
Street Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip
*
Phone Number
*
Alternate Phone Number
Email Address
*
🛈
Confirm Email
*
🛈
Any additional notes/comments regarding registration?
0/255 characters
Payment Information
Pay with
*
Cash
Check (payable to 'Sikh Center')
PayPal (Please follow link for payment on next page after you click submit)
Note: When 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.
Total amount due: $210
Total amount due: $400
Total amount due: $590
Parent/Guardian Consent
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
Emergency Contact
*
Phone Number
*
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