Dragons Eye Ventures

Summer 2012 Registration Form

Participants Name ___________________________________________ Date __________________
Circle: M

Age _____

Fall 2012 Grade _____ School & Town ______________________________

___________________________________________
Parent/Guardian

___________________________________________
Parent/Guardian

___________________________________________
Street Address

___________________________________________
Street Address

___________________________________________
City, State, Zip Code

___________________________________________
City, State, Zip Code

____________________
Day Phone

____________________
Day Phone

____________________
Evening Phone

___________________________________________
Email

____________________
Evening Phone

___________________________________________
Email

Alternative Emergency Contacts

___________________________________________
Name

_______________
Relationship to Child

______________________
Day Phone

___________________________________________
Name

_______________
Relationship to Child

______________________
Day Phone

_______________________________________
Physicians Name

_____________________
Physicians Phone Number

________________________
Hospital/Clinic Preference

_______________________________________
Insurance Company

_____________________
Policy Number

________________________
Date of last Tetanus shot

Medical Information

___________________________________________________________________________________________
___________________________________________________________________________________________
Allergies/Special Considerations

I certify that my child is in excellent health with no limit to participation in the Dragons Eye
program, except as stated in writing on this form. In the event that I cannot be reached during an
emergency involving my child, I waive my right to informed consent of treatment and I authorize first
aid and emergency treatment for my child.
___________________________________________________
Parents/Guardians Signature

______________________________
Date

Dragons Eye Ventures

Authorizations
Participants Name ___________________________________________ Date __________________
The following adults have my permission to pick up my child from the Dragons Eye Ventures program:
___________________________________________
Name

_______________
Relationship to Child

______________________
Day Phone

___________________________________________
Name

_______________
Relationship to Child

______________________
Day Phone

Notes:

An authorized adult must sign each participant in and out of the program. ID may be required.

___

I grant permission for my child to attend field trips with the Dragons Eye Ventures program.

___

Dragons Eye has my permission to use my childs photo and artwork for promotional materials.

___________________________________________________

______________________________

Parents/Guardians Signature

Date

Registration for Dragons Eye Ventures Summer 2012

Consecutive sessions are recommended but not required. Adventures may not be repeated.

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____
____
____
____
____

Session

Dates

Adventure

Fee

Afterhours

Subtotal

Session I
Session II
Session III
Session IV
Session V
Session VI

July 9 13
July 16 20
July 23 27
July 30 Aug 3
Aug 6 10
Aug 13 17

Star Chroniclers Journey

Turtle Mountain Dreams
Terra Incognita
Star Chroniclers Journey
Turtle Mountain Dreams
Terra Incognita

$275
$275
$275
$275
$275
$275

$50
$50
$50
$50
$50
$50
Total:

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_______
_______
_______
_______
_______
_______

Non-refundable deposit: $125/session is due upon registration as a non-refundable deposit.

The remainder is due by June 1, 2012. Some partial scholarships are available.
Payment may be made by check, made out to: Dragons Eye Ventures.
Mail payment & registration to: Dragons Eye Ventures, P.O. Box 718, Brunswick, ME 04011.

How did you hear about Dragons Eye Ventures? Please check any that may apply.
Dragons Eye:
___ Friend/Family
___ Newspaper

___ Brochure

___ Postcard

___ Poster

___ Parent & Family Magazine

___ Online Source

___ Website

___ Facebook

___ Portland Press Herald Camp Guide

___ Other: _____________________