Camp Wilder 2023 Registration Camper's InfoCamper's Name* First Last Date of Birth* DD slash MM slash YYYY Age*Interested in our Leader In Training program? We will contact you prior to camp if spots are available. *Must be 15-16 years old. Yes Name of School* Grade Entering this Fall*Weeks Attending (check all that apply)* Session 1: July 3-July 7 Session 2: July 10 - July 14 Session 3: July 17 - July 21 Session 4: July 24 - July 28 Session 5: July 31 - Aug 4 Tuition Payment Method ($300 or $250 Springfield Residents; $240 for Week 1)* I will be mailing a check before camp starts Cash or Check Upon Arrival Debit/Credit Card Upon Arrival (includes 3% fee) Make checks payable to "Next Level Adventures" and mail to: Next Level Adventures, 19 Rattle Hill Road, Southampton, MA 01073How did you hear about Camp Wilder? Select all that apply Website Flyer Previously Attended Newspaper Family/Friend Facebook Parent/Guardian InfoParent/Guardian Name* First Last Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Cell Phone*Email* Preferred method of contact* Cell Phone Email Make checks payable to "Next Level Adventures" and mail to: Next Level Adventures, 19 Rattle Hill Road, Southampton, MA 01073Emergency InfoEmergency Contact Name* First Last Emergency Contact's Relationship with Camper* Work/Cell Phone*We are required to have a copy of your camper's most recent physical and vaccinations (current year). Please bring the day of or mail to Next Level Adventures, 19 Rattle Hill Rd., Southampton, MA 01073.Please use this area below to list any medical conditions, allergies, or special needs the staff should know about. Also feel free to call us directly to discuss.I am aware that pictures of my child may be used for publicity purposes by one or more agencies and I consent to the use of such pictures.* Yes No Parent/Guardian Permission (Please type your full name to agree to the following terms)* My child has permission to participate in activities provided by agencies participating in the Recreation/Enrichment Programs. I acknowledge that my child must follow all of the rules in order to participate. In the event that I cannot be reached in an emergency, I hereby authorize that medical/surgical treatment be administered to my child at my expense. I assume all risks and hazards incidental to and inherent in participation in this program. I hereby waive and release the City of Springfield and its officials, employees and officers from any claims that arise out of a decision to authorize medical/surgical treatment, as well as claims arising out of any personal injury or property damage related in any way to my child’s participation in the program. I hereby indemnify and hold harmless those agencies or organizations providing activities for the Recreation/Enrichment Program from claims of third parties arising out of the decision to authorize medical/surgical treatment, or my child’s participation in the program. My name below authorizes the Springfield School Department to release my child’s social security, SASI, State ID numbers, and necessary school documents to the REACH and or CDGB partner program network. The information gathered will be used to apply for and report in grants the city receives. My full name above certifies that I have read and understood this disclaimer, and all the program rules and regulations.