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Camp High Rocks Camper Application Form

Current Photo (optional): (JPEG format only)
Camper's First Name:
Camper's Middle Name:
Camper's Last Name:
Camper's Preferred Name:
Parental correspondence
should be addressed to:
Home Address:
City:
State:
Zip Code:
Home Phone:
Preferred Email: (for correspondence)
Billing Email:

Mother's Information

First Name:
Last Name:
Business Phone:
Cell Phone:
Email Address:
Occupation:

Father's Information

First Name:
Last Name:
Business Phone:
Cell Phone:
Email Address:
Occupation:

2019 Dates and Rates

* Grade denotes 2018-2019 school year.

Session Dates Grades Rates
3 Weeks Sunday, June 9 - Friday, June 28 1st - 10th $5,350 
4 Weeks Monday, July 1 - Saturday, July 27 3rd - 10th $6,575 
Mini I Monday, July 1 - Saturday, July 13 1st - 5th $3,900 
Mini II Monday, July 15 - Saturday, July 27 2nd - 5th $3,900 
2 Weeks Monday, July 29 - Saturday, August 10 1st - 7th $3,900 
Birthdate: (mm/dd/yyyy)
Height: feet inches
Weight: pounds
Boy Scout? Yes
T-Shirt Size:
Brothers names and ages:
Sisters names and ages:
Do any sisters attend a North Carolina Camp?
If so, which camp?
Would you like information on area girls' camps?
Name of School:
Grade completed by June of 2019:
How did you learn of High Rocks?
Camps attended previously:
Years:
My son requests to be in a cabin with:
My son requests to NOT be in a cabin with:

Personal Information

What would you like for us to help your son accomplish during his stay at High Rocks?

Please list any medical or emotional conditions (i.e., enuresis, sleepwalking, ADD or ADHD, anaphylaxis, asthma), which would require special medical attention or added attention from our staff.

Does your son take prescription medication during the school year?
Will he continue them at camp?
Please list and explain:

Please list any food allergies or dietary restrictions. (We are able to make some accommodations for dietary restrictions and allergies. Please contact us for more information about our food and kitchen capabilities.)

Does your son have any learning disabilities? Explain:

Would you like to recommend friends to High Rocks

Name:
Email:
Address:
City, State, Zip:
Phone Number:
Son's Name:
Son's Age:

Name:
Email:
Address:
City, State, Zip:
Phone Number:
Son's Name:
Son's Age:

Type the word "Yes" in this box to confirm you have read and agree to
Acknowledgement of Risk and the Parent's Information Page.