Camp registration should be returned to Horizons Unlimited 1636 Parkview Circle Salisbury, NC 28144.
Payment expected at time of registration. Checks should be made to Horizons Unlimited.
Student Information: Please print all information clearly
Camp student will be attending: __________________________________________________________________________________________
Last Name: _____________________________ First Name: _____________________ Middle Initial: _____
Age: _______
Date of Birth: ____________
Male
Female
Address: ______________________________ City: __________________ State: ________ Zip: ________
Telephone Number: (_____)_________________________
Child resides with: ______________________________________ Relationship to child: ______________
Parent/Guardian 1:
Parent/Guardian 2:
Name: ________________________________
Name:__________________________________
Address: ______________________________
Address: ________________________________
City/Zip Code: __________________________
City/Zip Code: ____________________________
Phone: (_____)______________________
Phone: (_____)______________________
Phone 2:(_____)___________________
Phone 2:(_____)___________________
E-mail Address:_________________________
E-mail Address:___________________________
Emergency Contact Information: (Persons must be able to transport your child)
→ Parents/Guardians will be contacted FIRST.
Emergency Contact # 1 Name (Not parent/guardian):__________________________________________
Relationship to Child: __________________________________
Home # (_____ )_____________________
Cell # (______)_______________________
Work # (______)_____________________
Emergency Contact # 2 Name (Not parent/guardian): _______________________________________
Relationship to Child:__________________________________
Home # (_____)_____________________
Cell # (_____)_______________________
Work # (_____)______________________
Camper’s Name: ____________________________________________________________________________
(Print First and Last Name)
Health Information: Provide information on any medical conditions, psychological conditions, behavioral
conditions, medications, dietary restrictions, allergies or special needs that we need to be aware of to ensure your
child has a positive experience at Horizons Unlimited Summer Camp.
Expectations and Instructions: By signing this form, you are agreeing to the following rules and expectations for behavior:
1) I will participate in all programs with a positive attitude.
2) I will be helpful and follow directions given by adult leaders while I’m at the Event or Program.
3) I will use appropriate humor and language.
4) I will confirm with usual and customary standards of good citizenship, good decorum, and common courtesy.
5) I will follow all school and school system rules and policies although away from school as they are considered
applicable during the trip or program.
In the event that any of the above expectations or instructions is violated, the student’s participation may be immediately
terminated, a parent or guardian may be called to retrieve the student, and disciplinary action may be imposed.
This form must be read and signed by both parent/guardian and student.
**If this is not completed, your child cannot be accepted**
I request that the above-named student be allowed to participate in the trip or event planned and specifically consent to the
student’s participation.
If any emergency medical procedures or treatment are required during the trip, I consent to the trip supervisors taking,
arranging for, and consenting to the procedures or treatment in the supervisor’s discretion. I will be responsible for the costs
of any such medical procedures or treatment.
To the extent permitted by law, I agree to release the Rowan-Salisbury Board of Education, its individual members, agents,
employees and representatives (including program supervisors), from and against any claims which I or any other person,
firm, or corporation have or may have, known or unknown, arising out of, during, or in connection with the student’s
participation in the Horizon’s program. I further agree to indemnify, hold harmless, and reimburse the Rowan-Salisbury Board
of Education, its individual members, agents, employees and representatives (including all trip supervisors), if such a claim is
made. If the student is at least 18 years or age, he or she shall signify acceptance of and agreement to all the above conditions
and releases by signing where indicated below.
___________________________________________________________________________________________________________________________
Parent/Guardian Name (please print)
Signature
Date
__________________________________________________________________________________________________________________________
Student Name (please print)
Signature (Grades 6-12 only)
Date
_________________________________________________________________________________________________________________________
Address
Parent/Guardian Telephone: ____________________________________________________________________________