Name of Camper # 1(Required) First Last Date of Birth Camper # 1 MM slash DD slash YYYY Male/Female Camper # 1 Male Female Grade Camper # 1 Grade completed in June of 2023 Name of Camper # 2 First Last Date of Birth Camper # 2 MM slash DD slash YYYY Male/Female Camper # 2 Male Female Grade Camper # 2 Grade completed in June of 2023Name of Camper # 3 First Last Date of Birth Camper # 3 MM slash DD slash YYYY Male/Female Camper # 3 Male Female Grade Camper # 3 Grade completed in June of 2023Name of Camper #4 First Last Date of Birth Camper # 4 MM slash DD slash YYYY Male/Female Camper # 4 Male Female Grade Camper # 4 Grade completed in June of 2023 Name of Parent Completing Registration(Required) First Last Home PhoneHome Phone for ParentMobile PhoneMobile phone number for parentWork PhoneWork Phone for ParentAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mailing Address for Parent. This will be the address where all remaining paperwork will be sent.Email for Parent(Required) Email Address for ParentPick up List(Required)Please list all individuals approved by you that are allowed to pick up your child/ children. The parent listed above will automatically be added to the Pick Up list. Permission to Allow the Use of Sunscreen and Insect Repellant I agree to allow my child/ Children to use Sunscreen and Insect Repellant during camp in accordance with the permission statement. (See sunscreen and Insect Repellant Statement Below.)Use of sunscreen and insect repellent at Camp: NYS requires parental permission for your child to use sunscreen and insect repellent during camp hours. If sunscreen and insect repellent are going to be used by a camper, we suggest that it be applied before they arrive to camp. However, if you would like your child to be able to use either during camp hours, you must give permission below. Keep in mind that, 1) Sunscreen will only be used to prevent overexposure to the sun, and 2) Only sunscreen approved by the FDA for over-the-counter use will be permitted. Sunscreen is considered a drug, and will be checked and logged by the camp as such in accordance with the policies and procedures set forth in our Safety Plan. If your child will not be using sunscreen or insect repellent during camp hours you do not need to sign this section of the registration. Sunscreen and Insect Repellent Application Preferences Self Application Only Staff Assisted Only Either Would be Fine Please provide us with preferences regarding application of Sunscreen and Insect Repellent.General Photography/ Video Release I Agree to the General Photography/ Video Release. (See "Photography/ Video Release Below.General Photograph/Video Release: High Braes Refuge, Inc. will sometimes use photographs/video of the summer camping sessions for the purpose of presentations for campers, parents, supporters, potential supporters, churches, and our mailing lists, as well as any others individual or organization, High Braes Refuge, Inc. deems appropriate, to create awareness of our program. By signing below, you give High Braes Refuge, Inc. permission to use, as indicated above, photo images/video and voice taken by its employees and volunteers for the purpose of promotion and communication including internet, mail, email, and video production. High Braes Refuge, Inc. cannot guarantee your child will not be photographed/videotaped during the camping session but will guarantee that those images/voice will not be used as indicated above without your permission. Permission to Attend(Required) I give my child/ Children permission to attend the Day Camp program at High Braes Refuge.You must check this box in order to submit this form for registration of your child. THE "SUBMIT" BUTTON WILL NOT APPEAR UNLESS THIS BOX IS CHECKED. Name of Person Completing Form and Providing Permission(Required) First Last By placing your name here, you agree that you are the person completing this form, that all information is accurate to the best of your knowledge, and that you agree to all of the statements you have checked above. Δ
