National Humane Education Society & Briggs Animal Adoption Center 

Cool To Care Camp Registration Form

Please complete one form per child.  Completed form(s) must be received no later than May 23, 2008.  Email to education@nhes.org (copy and paste the form into the text box to complete), or print and mail to: NHES, c/o CTC, PO Box 340, Charles Town, WV 25414.

Please Note: Campers are registered via a lottery system.  Completion of this form does not guarantee a placement in the camp.  Please click here for the lottery registration details.

Registration Information

Child’s Name, Last:                                                     First:

Age/Grade Level

Parent or Guardian Name(s)

Last:                                                     First:                                       

Last:                                                     First:

Address

Street:                                                                                        

City:                                                     State:                           Zip:

Phone No. 

Home:                                                   Other:

Email:

Drop-off/pick-up of my child will be provided by, please indicate:

Myself

Other Parent or Guardian

Friend, Neighbor, Other (Please provide contact info)

     Name, Last:                                     First:                             Phone No.:

Emergency Contact

Name, Last:                                                     First:

Phone No.:

Relationship to Child:

Health Information

Insurance Provider and Policy Number:

Please list allergies:

Please list any dietary need(s) or special consideration(s) the child may have:

Camp Week, please indicate:

Grade 4-5, June 23-June 27, 2008, 10am – 2pm

Grade 6-8, July 21-July 25, 2008, 10am – 2pm