Pacific NW Leadership Girls Camp: Application Form

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Camp Details

Date:
June 18 - 22, 2012

Date/Time:
The camp starts at 3pm on June 18 and ends at 2pm on June 22. Parents and siblings are invited to join the campers for a surprise presentation at 11am on June 22, followed by a picnic lunch at the beach.

Location:
YMCA Camp Colman
20016 Bay Road KPS
Longbranch, WA 98351
Phone: 253.884.3844
(www.campcolman.org)

Cost:
Early payment discount (paid on or before May 10th): $360 per child;
$660 for two siblings.
After May 10th:
$430 per child;
$800 for two siblings.
Fee covers camp insurance, materials, rooms, and meals.

Carpool:
If you would like your daughter to carpool
to the camp, please enclose an additional $5
(per child) to help defray the cost of gas.

Make checks payable to:
PNWL Girls Camp

To apply (per child):
Please complete the forms:
- application form (print this page)
- YMCA Colman Release Form (print that page)
then enclose a $100 non-refundable deposit,
and mail to:
Vicky Renshaw
16210 SE 166th Court
Renton, WA 98058

Once your daughter has been admitted to the camp, please send the balance of the fee to secure her spot. Payment by installment is accepted. Full payment is due no later than June 10.

For more information, contact:
Maria de Alvare
503.807.1539
mdealvare@aol.com
Lucy Flores
503.691.7990
lucysflores@gmail.com
Vicky Renshaw
425.227.4509
blairandvicky@comcast.net

APPLICATION FORM

Full name: _________________________________________
Address:___________________________________________
City:_______________State:_____________ZIP:_________

Incoming Grade:_________________ DOB:_______________

Father's Name:______________________________________
Daytime telephone:_________________________________
Mother's Name:______________________________________
Daytime telephone:_________________________________
Parents' Email:______________________________________

Join Carpool: __Yes __No __One-way __Round-Trip
Can volunteer to drive for Carpool: __Yes __No

My daughter knows how to swim: __Yes __No

Participation Agreement:

PNWL Directors reserve the right to refuse admission or request withdrawal of any camper, if it is deemed necessary to protect the program's welfare.

The camp is not responsible for any lost, damaged, or stolen personal property.

Parents agree to abide by the camp rules.

Parents understand that any photographs or videos taken of their daughter during the camp activities may be used in future camp promotional materials.

Parents agree to hold the PNWL camp harmless from liability on account of injuries suffered by their child. Any claims for injuries shall be limited to the insurance coverage for the camp.

Medical Release Form:
____My daughter has no serious medical problem and may participate in any of the activities of the PNWL camp.
____My daughter has a medical condition that requires the following restrictions:
______________________________________________________
______________________________________________________

Consent for Treatment and Agreement of Terms:
I hereby give permission for my daughter to receive emergency medical care, should it be necessary during her stay at the PNWL camp. I also certify that I have read the Participation Agreement and agree to its terms.

_______________________________________ ___________
Parent/Guardian Signature Date