PLEASE CIRCLE CHOICE:  MANCHESTER JUNE 25-29   MANCHESTER JULY 9-JULY 13

PLEASE SPECIFY (CIRCLE):        FULL DAY (9-3)
                                HALF DAY - MORNING (9-12)  AFTERNOON (12-3)


NAME:______________________________________________________________________________
			(LAST)				(FIRST)

AGE_______________HOME PHONE_____________________________

ADDRESS:___________________________________________________________________________

TOWN:_____________________________________________ STATE:_________ ZIP:____________

EMERGENCY PHONE:(    )__________________________

PLEASE SEND A $100 DEPOSIT OR PAYMENT IN FULL

		 	($275 - TWO WEEK) ($150 - FULL DAY) ($75 - HALF DAY)

I waive and release The Connecticut Starter Camp from any and all liability from injury
and illness going to camp from home or while at camp or while returning home.
I, as parent/guardian, have actual knowledge and appreciation of the particulars of the program
and hereby voluntarily consent to said minor's participation, and assume the risk arising therefrom.
I hereby give my permission for emergency medical treatment in the event I cannot be reached.
Each youngster is subject to immediate dismissal if he or she does not comply with the camp rules and
regulations or if the student is found to be detrimental to the interest of the program. No refunds.


________________________________________________   DATE_______________________
Signature of Parent/Guardian

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