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Sawgrass nature center’s

Sawgrass Nature Center’s
“CAMP WILD” Break Camps 2012-2013
Counselor and Counselor In Training Application

Counselor’s Name __________________________________________________
Age: __________ Date of Birth: _______________________________________
School: _______________________________ Grade Completed: _____________
Parent(s)/ Guardian’s Name(s): ________________________________________
Relationship to Child: _______________________________________________
Mailing Address: ___________________________________________________
City: ______________________________ State: ____ Zip code: _____________
Home Telephone: ___________________________________________________
Cellular: __________________________________________________________
Best # to reach you: _________________________________________________
E-mail: ___________________________________________________________
Work Telephone for Mother: __________________________________________
Work Telephone for Father: ___________________________________________
Name of Additional Contact: __________________________________________
Additional Contact Telephone(s): ______________________________________
Do you give permission for your child to come and go from camp on their own?
If no, who is authorized to pick up your child (please include yourself)? 1. _____________________________________________________________ 2. _____________________________________________________________ 3. _____________________________________________________________
How did you hear about Camp Wild? _____________________________________________
MEDICAL INFORMATION
Physician and/or Health Care Facility: ___________________________________
Telephone Number: _________________________________________________
Allergies: _________________________________________________________
Special Medical Accommodations or Concerns
_________________________________________________________________
_________________________________________________________________
For headaches or insect bites, SNC staff may administer:
 Children’s Tylenol  Tylenol  Topical Benadryl  Oral Benadryl  Other _______________________________________________________  Prescribed Medications (*see statement titled Health Care Release) ________________________________________________________________________
LIABILITY RELEASE (Please Read, Sign and Date)

I, the undersigned, in my individual capacity as parent or guardian of
____________________________________, age, ______ being a minor child, hereby release
and hold harmless The Sawgrass Nature Center & Wildlife Hospital, its officers, employees,
instructors, and supervisors from any and all liability or damages, both personal and property,
arising out of or as a result of said minor child’s attendance at the Sawgrass Nature Center’s
Camp. I assume all risks, incident thereto with respect to myself and to any other individuals for
whom this registration is made.
Signature of Parent or Guardian ___________________________________________________
Date ____________
HEALTH CARE RELEASE
I give permission for the Sawgrass Nature Center, its officers, employees, instructors and
supervisors to provide routine health care, administer prescribed medications, and seek medical
treatment if an incident arises.
Signature of Parent or Guardian ___________________________________________________
Date ____________
MEDIA RELEASE

I understand that my child , may be filmed/photographed/interviewed
during camp, and give my permission for The Sawgrass Nature Center & Wildlife Hospital to
use my child’s photograph/work/voice for promotional and educational purposes.
Signature of Parent or Guardian ___________________________________________________
Date __________
Counselor Agreement
I ________________________________, (print your name) agree to adhere to all
Camp Rules and Regulations and I understand that any infractions may result in
me being asked to leave the Camp.
Counselor’s Signature ________________________________ Date__________
Please register by circling the days you wish to attend the break camp.
CIT slots will not be secured until registration fees are received for all days
indicated. The fee is $25/day.

Winter Break Camp:

 Dec. 24, 26 - 28 (Circle all that apply)  Dec. 31, Jan. 2 – Jan. 4 (Circle all that apply) M W Th F

Spring Break Camp:

 Mar. 25 - 29 (Circle all that apply) CIT Total $ _____________

CIT’s staying after 3:30pm will need to be pre-approved.

 I Prefer to pay by Check - please make payable to the: Sawgrass Nature Center
 I prefer to pay by Credit Card - please provide the following: Credit Card number _____________________________
Expiration Date___________
Signature ________________________________________ Date__________
Please mail or bring application and payment to the:
Sawgrass Nature Center
3000 Sportsplex Drive, Coral Springs, FL. 33065-2140
(954)752-WILD

Source: http://sawgrassnaturecenter.org/wp-content/uploads/2008/04/CIT_Application_BreakCamps_2012-13update.pdf

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