GRAFTON PONDS OUTDOOR CENTER
2015 MOUNTIN BIKE & NATURE CAMPS
REGISTRATION FORM
REGISTER TODAY TO RESERVE A SPOT!
Thank you for participating in this summer’s Mountain Bike & Nature Camp Program at Grafton Ponds
Outdoor Center. Please read the following information carefully. We have tried to answer all of the
questions you might have about the camps. However, if specific issues are not addressed, please contact
us: Grafton Ponds: (802) 843-2400, [email protected].
 All registrations must be accompanied with either full payment or with a 50% deposit. All outstanding fees
must be paid in full by the beginning or your camp week.
 A 75% refund will be available if a camper must cancel two weeks prior to camp. Within two weeks, a 50%
refund will be made.
 Space for camps will be based on a first-come, first-serve basis. Please use one form per child.
 A confirmation / detailed information packet will be mailed out immediately upon receipt of your registration.
The program has a limited number of camp scholarships available. If a need exists, please send a letter to the
scholarship committee and mail to Grafton Ponds, Attn: Angela Comstock, PO Box 9, Grafton, VT
05146. Additional support may also be available from your local schools, church or civic organizations.
Please circle the camp week or activity you would like to attend; indicate if you have a 2 nd or 3rd choice if
your initial request for a camp date is filled. If a camp is filled we will contact you immediately.
MOUNTAIN BIKE CAMPS
CAMP #1-Beginner
Mountain Bike Camp
(JUNE 22ND-26TH)
Minimum age 5
CAMP #2-Intermediate to
Advaced
Mountain Bike Camp
(JUNE 29th-July 3rd)
Recommended ages 7-10
CAMP #3- Intermediate to
Advanced
Mountain Bike Camp
(JULY 20th-24th)
Recommended ages 11-16
CAMP #5- Intermediate to
Advanced
Mountain Bike Camp
(AUG. 3rd-7TH) A
Recommended ages 11-16
CAMP #4- Intermediate to
Advanced
Mountain Bike Camp
(JULY 27TH-July 31ST)
Recommended ages 7-10
Camp #6-Beginner
Mountain Bike Camp
(AUG. 10TH-14th)
Minimum age 5
CAMP #7-Advanced
Mountain Bike Camp
(AUGUST 17TH-21st)
Recommended ages 11-16
Male / Female
(circle one)
____________________________________________
Camper’s Name
________
Age
____________________________________________
Parent’s Name (print)
_______________________
Home Phone & Emergency Phone
_______________________________________________________________________
Mailing Address
____________________________________________
Parent’s Signature
_________
Date
_______________________________________________________________________
*Addt’l Emergency Contact, Relationship & Phone
Before 5/15
$225
RATES
PAID
5/16 -6/1
$250
After 6/1
$325
$50 additional for bike rental
25% off each additional child
Checks payable to:
Grafton Ponds Outdoor
Center Mail to: Summer
Camps Attn: Becky Bryant
225 Townshend Rd, Grafton,
VT 05146
Camp Fee
________
Bike Rental
________
TOTAL
_______
Payment type:
CC
Check
Money Order
CC#_______________________________
Expiration ________
2015 MOUNTAIN BIKE & NATURECAMPS
Grafton Ponds Outdoor Center
783 TOWNSHEND ROAD, PO BOX 9, GRAFTON, VT 05146 802-843-2400
GRAFTONPONDS.COM
[email protected]
LIABILITY RELEASE FORM
All parents who have children participating in the 2014 Mountain Bike & Adventure Camp
Program at Grafton Ponds must read and complete a liability release form. A parent or guardian
must sign and mail in the form below at least two weeks before their designated camp begins.
________________________________________________________
Parent’s name (print)
________________________________________________________
Camper’s name(print)
________________________
Phone
__________________________
Email
________________________________________________________
Address
Warning: the above named camper, a participant in the 2014 Mountain Bike & Nature Camp
Program at Grafton Ponds, and their parent or guardian understand that mountain biking,
hiking, group games, swimming and pond exploring are hazardous and physically demanding
activities and recognizes that variations in weather, trails, forest growth, rocks and other hazards
or obstacles exist at any outdoor recreation facility. Through the act of participating, such
dangers are recognized and accepted whether they are marked or unmarked. The participant
also realizes that falls and collisions do occur and injuries may result, and therefore assumes the
burden of remaining under control at all times. Upon participation, I hereby, for myself, my
heirs, executors and administrators waive and release any and all right s and claims for damages
I may have against Grafton Ponds, their representatives successors and assignees, and will hold
them harmless for any and all injuries suffered in connection while participating in activities at
Grafton Ponds including those which may be attributable to acts of nature and weather
conditions. All camp privileges may be revoked by the management at any time without refund
and are nontransferable.
________________________________________________
Parent or Guardian Signature
________________________
Date
2015 MOUNTAIN BIKE & NATURECAMPS
Grafton Ponds Outdoor Center
783 TOWNSHEND ROAD, PO BOX 9, GRAFTON, VT 05146 802-843-2400
GRAFTONPONDS.COM
[email protected]
MEDICAL HEALTH & INFO. FORM
All parents who have children participating in the 2015 Mountain Bike & Nature Camp Program at
Grafton Ponds must complete a medical health and information form. A parent or guardian must sign
and mail in the form below at least two weeks before their designated camp begins.
*Please use the reverse side of this form to elaborate on any of the below.*
____________________________________________________________________________
Camper’s name(print)
___________________________________________
_______________________________
Address
City, State, Zip
____________________________
____________________________________________
Phone
Email
____________________________________________________________________________
Parent’s Emergency Contact #’s
____________________________________________________________________________
Doctor’s Name & Phone #
____________________________________________________________________________
Family Health Clinic & Phone #
________________________________________________________
Health Insurance Co. & Policy ##
Describe any challenges your child has with hearing, vision, medications, other (physical and/or
emotional) _______________________________________________________________________________
_________________________________________________________________________________________
Please list any allergies that your child may have to such things as bee stings or medicines like penicillin:
_________________________________________________________________________________________
_________________________________________________________________________________________
Will your child need to receive any medications during camp hours?
YES NO
If YES, please provide information on the medication, time(s) of administration and if assistance is
needed from camp director. _________________________________________________________________
_________________________________________________________________________________________
Are there any medical limitations we should be aware of? YES NO
If YES, please provide details.
_________________________________________________________________________________________
General permission to administer over the counter medications & treatment:
Tylenol YES NO Benadryl YES NO Insect Repellent (deet) YES NO
Calamine Lotion YES NO
I authorize permission to use an emergency care provider to make the necessary decisions in the event that I am not
able to be reached.
YES NO
__________________________________________________________
Parent or Guardian Signature
_____________________________
Date
2015 MOUNTAIN BIKE & NATURECAMPS
Grafton Ponds Outdoor Center
783 TOWNSHEND ROAD, PO BOX 9, GRAFTON, VT 05146 802-843-2400
GRAFTONPONDS.COM
[email protected]
PARENTAL PERMISSION
____________________________________________________ _______________________
Camper’s name
Scheduled Camp Week
All parents who have children participating in the 2015 Mountain Bike & Nature Camp program
at Grafton Ponds must fill out a permission form. A parent or guardian must sign and mail in the
form below at least two weeks before their designated camp begins.
 Traveling Out of Grafton
During the camp week, participants will have an opportunity to travel outside of Grafton to
explore other Southern Vermont state forests or wilderness areas. Parental permission is
required to allow children to participate in this offsite program.
I hereby give permission to Grafton Ponds to allow my child to travel outside of Grafton during
scheduled activities associated with the 2014 Summer Camp program.
___________________________________________________________________
Parent or Guardian Signature
_________________________
Date
 Arriving/Leaving Camp
Will your child arrive or leave camp with someone other than a parent or guardian?
YES
NO
If yes, please complete the following:
Caregiver’s name__________________________________________________________
Address & Phone ______________________________________________________________
I hereby give permission to Grafton Ponds to allow my child to be dropped off or picked up by a
designated caregiver during the 2014 Summer Camp program.
___________________________________________________________________
Parent or Guardian Signature
________________________
Date
2015 MOUNTAIN BIKE & NATURECAMPS
Grafton Ponds Outdoor Center
783 TOWNSHEND ROAD, PO BOX 9, GRAFTON, VT 05146 802-843-2400
GRAFTONPONDS.COM
[email protected]
PHOTO RELEASE FORM
From time to time, we hire professional photographers to take photos of our facilities and
guests using them. If we do schedule a photographer during camp, we ask for permission
to use photos that may include your children. The photo release portion is below. If you
are amenable with this, please sign the form below and include it with your completed
registration forms. Thank you.
I hereby give my consent to the Windham Foundation, Inc. to use any photographs taken
during this photo shoot for the organization, including its subsidiaries: Grafton Ponds
Outdoor Center, the Grafton Inn, Grafton Village Cheese Co., or Retreat Farm. This
includes using the photos in promotional material, including its websites, print collateral
and publicity materials in perpetuity. All photos will be owned by the Windham
Foundation.
I release Windham Foundation from any expectation of confidentiality for myself.
Name of Camper:____________________________________________________________
Parent Signature: __________________________________________ Date: ___________
Parent Printed name:_________________________________________________________