Camp Forest 60 Payson Road ~ Brooks, ME ~ 04921 ~ (207) 722-3708 ~ 1-888-760-7943 Please print, complete and mail or your registration form. 2012 Season Extender Registration Form Camper Name: Age:      DOB:          Gender:     Parent/Legal Guardian Name(s): Address: City:        State:    Zip:      Home Phone: ( ) Work Phone: ( ) Email Address: Emergency Contact: Emergency Phone: ( ) Check Weeks Desired - $40 per day: Group Rates available March 3 March 10 March 17 March 24 March 31 April 7 April 14 April 21 April 28 May 5 May 12 May 19 May 26 June 2 June 9 June 16 June 23 Sept 8 Sept 15 Sept 22 Sept 29 Oct 6 Oct 13 Oct 20 Oct 27 Is there anything physical, mental, or emotional about your child we should know? Is there anything in particular you would like us to know about your child? Medical Information: Please bring a copy of child's up-to-date immunization record. Date of Last Tetanus Shot: ____________________ Does child have: ____Heart Trouble ____Epilepsy ____Asthma ____Allergies< Does child take medications regularly? ____Yes ____No If so, please list: _____________________________________________________________ Insurance Name:______________________________ Number:________________________ Doctor's Name: ____________________________ Telephone: __________________________ Please complete and mail with your $50.00 non-refundable registration fee. ____Check/Money Order Enclosed ____MC/Visa #___________________ Ex Date__________   Permission form will be mailed to you.   We look forward to seeing you at camp!