8/18/2019 2016 Northern Registration Form

1/2

 

MECKLENBURG COUNTY PARK AND RECREATION DEPARTMENT

Therapeutic Recreation

REGISTRATION FOR SUMMER DAY CAMP !"#

NORT$ERN AD%ENTURES & YOUT$ AND TEENSMUST COMPLETE ONE '"( FORM PER CAMPER ) ** PLEASE PRINT **

CAMPER'S NAME: _______________________________________________________________________________ 

AGE: _______________ DOB: ____/____/____ SEX: M  F

T-SHIRT:  Youth Small  Youth M!"um  Youth #a$%  A!ult Small  A!ult M!"um

 A!ult #a$%  A!ult X#  A!ult &X#  A!ult X#(O) T-*h"$t +$ +a$t","+a)t "* "),lu!! ") Summ$ Da Cam+ $%"*t$at"o).

ADDITIONA# T-SHIRT FEE: +",-!! per .hirt    Ch, "0 ou a$ +u$,ha*")% a) a!!"t"o)al T-*h"$t

DISABI#ITY:

PARENT/G1ARDIAN NAME:

ADDRESS:

CITY: STATE: 2IP:

HOME PHONE: 3OR4 PHONE: CE## PHONE:

EMAI#:

3 Ch,  3*

Att)!")%

Dat* (5 6 7& a$* ol!.Northern A/0enture ) Youth

Torrence L1t2e Co33unit1 Center

8:9 am 6 :9 +m

(7 6 &7 a$* ol!.Northern A/0enture ) Teen

Torrence L1t2e Co33unit1 Center

8:9 am 6 :9 +m

7 5/7 6 5/7;

8/18/2019 2016 Northern Registration Form

2/2

ADA State3ent

Th M,l)@u$% Cou)t Pa$ a)! R,$at"o) D+a$tm)t "ll ,om+l "th th Am$",a)* "th D"*a@"l"t"* A,t (ADA.h",h +$oh"@"t* !"*,$"m")at"o) o) th @a*"* o0 !"*a@"l"t= M,l)@u$% Cou)t "ll ma $a*o)a@l a,,ommo!at"o)* ")all +$o%$am* to )a@l +a$t","+at"o) @ a) ")!""!ual "th a !"*a@"l"t ho mt* **)t"al l"%"@"l"t $u"$m)t*=M,l)@u$% Cou)t +$o%$am* "ll @ aa"la@l ") th mo*t ")t%$at! *tt")% 0o$ a,h ")!""!ual= I0 a)

a,,ommo!at"o)* a$ ),**a$ 0o$ +a$t","+at"o) ") a) +$o%$am o$ *$", +a$t","+a)t* a$ ),ou$a%! to )ot"0 *ta00 atth t"m o0 $%"*t$at"o) o$ at la*t 8 hou$* +$"o$ to +$o%$am ,omm),m)t= 1+o) $u*t th"* ")0o$mat"o) "* aa"la@l") a) alt$)at" 0o$mat 0o$ +$*o)* "th !"*a@"l"t"*=

M,l)@u$% Cou)t Pa$ a)! R,$at"o) l,om* +o+l o0 all a@"l"t"* to ou$ +$o%$am*=

Inc2u.ion State3ent

M,l)@u$% Cou)t Pa$ a)! R,$at"o) D+a$tm)t @l"* ") th alu o0 "),lu*" l"*u$ a)! $,$at"o)+$"),* 0o$ all mm@$* o0 th ,ommu)"t $%a$!l** o0 th"$ ll o0 a@"l"t= Th D+a$tm)t ma* $ 00o$t to)*u$ "),lu*" o++o$tu)"t"* ") all +$o%$am *$",* "),lu!")% +a$* 0a,"l"t"* +$o%$am* *+,"al )t* a)! ,la***=

Con.ent an/ Re2ea.eI Pa$)t o$ Gua$!"a)* Nam h$@ %$a)t +$m"**"o) 0o$ th +a$t","+a)t Cam+$* Nam to ta +a$t ") th Summ$Da Cam+ +$o%$am h",h "* *+o)*o$! @ th M,l)@u$% Cou)t Pa$ R,$at"o) D+a$tm)t=

I al*o a%$ o) @hal0 o0 m*l0 a)! th +a$t","+a)t )ot to ma a) ,la"m* o$ !ma)!* o0 a) ")! a%a")*tM,l)@u$% Cou)t o$ a) o0 "t* m+lo* o$ a%)t* 0o$ a) lo** o$ ")u$ that th +a$t","+a)t m"%ht *u*ta") h"l)%a%! ") th TR Summ$ Da Cam+ +$o%$am "),lu!")% t$a)*+o$tat"o) to th +$o%$am *"t=

I autho$" *u,h +h*","a) o$ m!",al *ta00 a* th M,l)@u$% Cou)t Pa$ a)! R,$at"o) D+a$tm)t m !*"%)atto ,a$$ out a) m")o$ m!",al/*u$%",al t$atm)t a)!/o$ m!",at"o) ),**a$ o$ to ta th +a$t","+a)t to th )a$*tm$%), 0a,"l"t a)! I/ 0u$th$ autho$" "t* m!",al *ta00 to +$o"! a) t$atm)t !m! ),**a$ 0o$ th ll- @")% o0 +a$t","+a)t=

I al*o a%$ that +hoto%$a+h* a)!/o$ "!o* o0 th +a$t","+a)t ma @ +u@l"*h! 0o$ th +u$+o* o0 +u@l","")% a)! +$omot")% +$o%$am* o+$at! a)!/o$ *+o)*o$! @ th M,l)@u$% Cou)t Pa$ a)! R,$at"o) D+a$tm)t=

A 0ull $0u)! "ll @ "**u! 0o$ +$o%$am* ,a),ll! !u to lo )$ollm)t o$ "),lm)t ath$= A +a$t"al $0u)! ($0u)!m")u* a 79J *$", ,ha$%. "ll @ "**u! h) th $%"*t$a)t *u@m"t* a $"tt) $u*t 0o$ a $0u)! a m")"mum o0 t)(79. !a* @0o$ th +$o%$am *ta$t !at= A +a$t"al $0u)! (m")u* a 79J *$", ,ha$%. "ll al*o @ a++$o! "0 th$%"*t$a)t *u@m"t* a +h*","a)* ltt$ a!"*")% a%a")*t +a$t","+at"o) @0o$ th 0"$*t ***"o)=

NO REFUND "ll @ a++$o! l** tha) t) (79 !a*. @0o$ th 0"$*t !a o0 a,h o0 ,am+ ("thout a +h*","a)*ltt$.=

Si9nature o: Parent8Guar/ian ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;

Date;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; 

KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK=OFFICE USE ONLY

R,"! @: Sta00: _________________________________________ Dat: _____________