COUNSELOR-IN-TRAINING *
Registration Form
Kids Camp, Inc. 2016
* For Children Ages 13 & 14 willing to ASSIST and LEARN at Camp.
Please complete one form for EACH Child attending.
CIT Name: Last _________________________________________ First ______________________________________ Birth Date __________________________ Grade completed as of May 2015
_______________ Gender:
M
F
Billing Address _________________________________________________________________________________ City ________________________________________________ State __________________ Zip Code ____________________ Parent/Guardian Name: __________________________________________ Email _________________________________ Home Phone: _____________________ Work Phone: __________________________ Cell Phone ___________________ Special Skills/Talents: ___________________________________
CIT’s & Parents MUST Sign a Contract
2016 Camp Schedule – Check ALL Weeks to Attend
Birth Certificate MAY be Required to Enroll Attendance at Training Day in MAY is Required
Week 1 May 31-June 3
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Week 2 June 6 – June 10
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Week 3 June 13 – June 17
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Week 4 June 20 – June 24
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Week 5 June 27 – July 1
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Week 6 July 5 – July 8
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Week 7 July 11 – July 15
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Week 8 July 18 – July 22
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Week 9 July 25 – July 29
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Week 10 August 1 – August 5
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Week 11 August 8 – August 12
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Week 12 August 15 – August 19
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Total Number of Weeks
_____
A $25 Change Fee Applies after 6/1/15
CIT Payment Worksheet The CIT program is reserved for FULL WEEK Enrollments ONLY PARENT must be a member for SRFC Price Weekly Camp Fees Before 4/30/15 Before 6/1/15 After 6/1/15
SRFC Member - $80 SRFC Member - $90 SRFC Member - $100
Non-Member - $99 Non-Member - $109 Non-Member - $119
Fee per Week
___________
Total Number of Weeks
x ___________
No Additional Discounts Apply for CIT Participants TOTAL
___________
Deposit Due April 30, 2015 – 50% of Total
___________
Final Balance** Due May 30, 2015 – Remainder
___________
Registration and Participation Agreement & Terms
Refunds will NOT be given after this date
I understand THE WAIVER ON THE REVERSE SIDE MUST BE REVIEWED AND SIGNED and Current Contact/Medical Information MUST be provided PRIOR to my child being admitted to and attending Kids Camp. I understand that payment of the prescribed Deposit by its due date reserves a place for my child in Kids’ Camp. (KC) and that priority will be given to SRFC members and full summer campers. I further understand that payment of the deposit by the due date determines eligibility for the early registration discount and that all Final Balance Payments must be received by the due date indicated, and that failure to do so may result in additional costs and prevent my child from attending camp until final balance is paid in full. A portion of this deposit is nonrefundable in the event of cancellation. Camp activity schedules may be adjusted due to weather and as camper enrollment increases and decreases, and are also subject to change anytime, without prior notice and for any reason. Certain children may have special needs and limitations beyond the scope of our camp structure and parents are REQUIRED and expected to inform KC in advance of special circumstances and needs so that an enrollment evaluation and determination can be made. Enrollment is not guaranteed by payment. Behavior agreements from certain parents for particular children may be required for enrollment and or continued camp participation. Refunds are not issued after May 30, 2015, and a $25 change fee applies for any and all changes made to camper attendance schedules after 6/1/15.
___**I Authorize an Automatic Charge MY Credit Card for the Balance on May 30th, 2015 – PROVIDE CC INFO BELOW
___________________________________________ PARENT/GUARDIAN SIGNATURE
___________ Date
A Completed form with payment info may be Fax’d to:217 787-2131 Method of Payment: ___VISA ___CHECK
___MC ___CASH
___DISC
___AMEX
MAKE CHECKS PAYABLE to Kids Camp, Inc. Payment Amount $_____________________ CREDIT CARD NUMBER _________________________________
Expiration Date _____________________
CVR CODE
________________
Print Name: _____________________________________________ Signature _______________________________________________
