Adventurelore Summer Camp Registration Forms

ADVENTURELORE SUMMER PROGRAMS
…..SAVE THIS PAGE ….CAMP PACKING LIST ON BACK…
Welcome to our 2015 Adventurelore Summer Program! Our 34th year!!! For those of you coming to
Adventurelore for the first time, you may be a bit nervous ahead of time, especially the night before and the
morning of your trip. That’s OK- most are! Just be reassured, as soon as the activities begin, before we load up the
vans, each adventurer will be one of the group and part of the fun. After a long, cold winter, take advantage of the
warmer temperatures. Now is the time to get outside, take a walk, a run, or bicycle. Any physical activity you
enjoy most works great! So, get out, get active and even get your family involved!
Enclosed are our camp forms. Please complete, sign and return to us ASAP. Now is not too early!
A $ 200.00 (non-refundable) deposit per program is necessary for registration. We are unable to hold a spot
without this deposit. The deposit is deducted from the total cost of the program. We accept MASTERCARD,
VISA, DISCOVER . Balance is due by June 15, 2015.
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All camp programs leave from our headquarters in Danville, NH. We provide transportation to camp locations.
PROGRAMS
ARRIVE @ DANVILLE:
5 Day JR 1 Woodstock (June 29 - July 3)
5 Day JR 2 Woodstock (July 13 – July 21)
6 Day JR 3 Franklin, ME (July 27 - Aug 1)
Monday, June 29 @ 10:00 am
Monday, July 13 @ 10:00 am
Monday, July 27 @ 9:00 am
8 Day XC Challenge (June 29 - July 6)
8 Day Land & Sea (July 9 - July 16)
8 Day White Mtn. (July 21 - July 28)
6 Day GIRLS Adv. (July 20 - July 25)
am
Monday, June 29 @ 9:00 am
Thursday, July 9 @ 9:00 am
Tuesday, July 21 @ 10:00 am
Monday, July 20 @ 9:00
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Each program returns to Danville at approximately 3 pm. We will make every effort to contact you
should this change. Please allow some extra time for the post–trip conferences!
MONEY? Campers don’t “need” money but may wish to bring some for souvenirs, store stops, ice cream, etc.
Any questions you have, we can answer! Call us @ 603-382-4661, email us @ adventurelore@hotmail.com
P.O. Box 395 197 Long Pond Rd. Danville, NH 03819
Phone (603) 382-4661 Fax (603) 382-0571
Website: www.adventurelore.org
Email: adventurelore@hotmail.com
We’re ready for another FUNtastic summer. All we need is you!
ADVENTURELORE PACKING LIST
We recommend you use a duffle bag. On your arrival day, please bring a small
day pack with your own lunch, water, bathing suit and towel.
PLEASE LABEL EVERYTHING! Unclaimed clothing is donated to charity. We are not
responsible for lost or stolen valuables (ipods, jewelry, etc.) Use of personal cell phones will not
be allowed during programs. Cell phones will be collected by our staff and returned at the end
of the program.
ALL PRESCRIPTION MEDICATION MUST BE GIVEN TO ADVENTURELORE STAFF @
REGISTRATION.
RECOMMENDED ITEMS:
___ Sleeping Bag / Pillow
___ Tent (1-2 person)
___ Flash Light
___ Mess Kit
___ Water Bottle/Canteen
___ Compass
___ Whistle
___ 2 pr. Sneakers or
___ 1 pr. Sneakers/1 pr. Hiking Boots
___ 1 pr. Warm Socks
___ Underwear & Socks (for length of trip)
___ Bathing Suits (2)
___ Beach Towels (2)
___ Water Shoes/sneaker/sandal type
___ Shorts/T-Shirts (for length of trip)
___ 2 pr. Jeans/Long Pants
___2 Sweat Shirts / Sweat Pants
___2 Poly Pro/Tek Wick T-Shirts
(esp. XC & WM trips)
___ Rain Coat / Poncho
___ Bandanna
___ Hat (w/visor)
PERSONAL ITEMS:
____Medications (staff will administer)
___ Soap, shampoo (biodegradable)
___ Toothbrush, toothpaste
___ Deodorant
___ Sun Screen (non-aerosol)
___ Insect Repellant (non-aerosol)
___ Comb, brush
___ Chapstick
OPTIONAL ITEMS:
___ Disposable Camera
___ Sunglassses
___ Air Mattress/cushion
___ Ground Cloth
___ Trash Bag/Zip Lock bags
___ Swiss Army Knife (folding type)
(acceptable on Senior Trips with staff
knowledge)
ITEMS NOT ALLOWED….knives, weapons,
slingshots, fireworks, tobacco products of
any kind, alcohol, drugs.
ADVENTURELORE SUMMER PROGRAMS
Acknowledgment of Risk and Liability Release Form
Adventurelore is extremely proud of our safety record. We encourage parents and participants to discuss any safety concerns with
us. We bring together a carefully selected, trained and experienced staff to provide quality programs. Safety is of paramount
importance. However, despite our best capabilities, the possibility of an accident does exist and it is impossible to guarantee that
injury will not occur. Therefore, as a condition of acceptance and participation in our program, we ask that you read and sign this
form.
In consideration of the services of Adventurelore Programs (including all counseling components), its agents, owners, officers,
employees, sub-contracted members and all persons or entities acting in any capacity on its behalf, I agree to release and
discharge Adventurelore on behalf of myself, my heirs, assigns, personal representative and estate as follows:
1.
I understand and acknowledge the activity my child will engage in bears known and unanticipated risks that could result
in injury, illness. disease, emotional distress, death. and/or damage to third parties. The following describe some, but not
all risks of injury and/or damage as a result of hiking, canoeing, kayaking, sailing , water skiing, camping, bouldering,
rock climbing, fishing, wrestling, trampoline use, ropes course, rappelling, bicycling, swimming, boating, white water
rafting, games and activities. (Note: your child’s participation may not include all of these mentioned activities. In order
to insure safety, we reserve the right to alter program formats due to weather and/or other unforeseen circumstances.)
2.
I agree to accept all risks existing in our activities. My child’s participation is purely voluntary, not forced.
3. I agree to hold harmless, release, forever discharge and indemnify Adventurelore from any and all claims, demands,
liability and/or actions that may occur with my child’s participation in activities including those allegedly attributed to the
negligent acts or omissions of Adventurelore.
4. Should Adventurelore or anyone acting on its behalf be required to incur attorney’s fees and costs to enforce this
agreement, I agree to indemnify and reimburse them for such fees and costs.
5. I certify my child has health, accident and liability insurance to cover any bodily injury or property damage caused while
participating in your program. I agree to bear the costs of such damage or injury.
6. I fully understand and acknowledge this agreement includes but is not limited to any bodily injury or property damage
that is sustained on or in connections with the use of any premises, property or real estate owned in whole or in part by
Adventurelore.
7. By signing this document, I acknowledge that if anyone is hurt or property is damaged during my child’s participation in
this program, I will have no right to make a claim or file a lawsuit against Adventurelore, its agents, owners, officers,
employees, sub-contracted members, or any other person or entity acting in any capacity on its behalf even if they
negligently cause such injury or damage.
My signature indicates I have read, understand and agree to its terms.
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Parent /Guardian Signature
________________________________ _______________
Print Name
Date
P.O. Box 395 197 Long Pond Rd. Danville, NH 03819
Phone (603) 382-4661 Fax (603) 382-0571
www.adventurelore.org
Adventurelore Summer Program
NAME:
PROGRAM:
ADDRESS:
Phone:
Cell:
Work:
Referred by:
EMERGENCY CONTACTS:
PERSONAL INFORMATION:
Age:
DOB:
Height:
Weight:
**Please include a recent picture **
Hair color:
Eye color:
INFORMED CONSENTS:
I hereby give consent and authorize, in case of an emergency, and in the event all reasonable
attempts to contact me have been unsuccessful, for the administration of any X-ray
examination, anesthesia, medical and surgical diagnosis and/or treatment, and hospital care
deemed necessary by a licensed physician and supporting second-opinion licensed physician
SIGNATURE of parent(s) or guardian(s):
Pictures taken during our programs may or may not be used for advertising purposes. By
signing this release, I authorize Adventurelore to use photos at their discretion on
brochures,videos or website.
SIGNATURE of parent(s) or guardian(s):
MEDICAL INSURANCE INFORMATION:
Insurance carrier:
Policy number:
Phone#:
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Adventurelore Summer Registration
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Primary Care Physician:____________________________Phone_______________________
Address__________________________________________________________________
Other physicians (if necessary):
____________________________Specialty__________________Phone_______________
____________________________Specialty__________________Phone_______________
General Health:
Excellent____
Good ____ Fair____
Date of most recent well check up___________________
Date of last tetanus___________
Eyeglasses
Asthma
Seizures
Enuresis
Allergies
yes____
yes____
yes____
yes____
yes____
no____
no____
no____
no____
no____
Contact lenses
Sleep Walking
Nightmares
Diabetes
Migraine
yes____ no____
yes____ no_____
yes____ no_____
yes____ no_____
yes____ no_____
ALLERGIES to medications:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Food Allergies: ___________________________________________________________
_______________________________________________________________________
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Medications:
Name:
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
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Dosage:
______________
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Reason for taking:
_______________________
_______________________
_______________________
_______________________
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_______________________
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On this page, please note any pertinent information related to the physical, medical
history or well being of this child. Please include any precautions for medications,
any special arrangements or considerations you would like us to know. (This
information may also be word-processed.)
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To help our staff become familiar with your child, kindly take a few moments and
tell us, in your own words, about your child, his/her strengths and weaknesses, etc.
Please be as candid and descriptive as possible, as the more informed we are about
each and every child, the better prepared we can be to provide the ideal program
experience. (This page may also be word- processed).
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