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Girl/TAG Kamp Konocti
Registration Form 2015
Camper Information
Mail completed registration with fees to:
Kamp Konocti P.O. Box 186
Windsor, CA 95492
Name: _______________________________________________________
Phone #:_____________________________________
Address: _____________________________________________________
Emergency Phone # for use during camp: ___________
City, State, Zip: ________________________________________________
Kamp Konocti Program: 1st choice:_________________
Email: _______________________________________________________
2nd choice: ____________________________________
May we email your confirmation packet instead of sending a paper copy?  Yes  No 3rd choice: _________________________
Registered Girl Scout?  Yes  No (Must register prior to camp) Grade Next Fall: _________ Troop # : ____________________
T-shirt Size: Youth Small Medium Large
Adult Small Medium Large X-Large XX-Large
Payment Information
$ __________ Camp Fees
$ __________ (-) Volunteer Discount ($100 off
one child’s fees only)
$ __________ Total Camp Fees
* Deposit of $50 is required to register.
Amount paid:
Ck#
*Payment is due in full one month prior to camp.
*Refunds, less $50 deposit, will only be issued if
cancelled by June 20, 2015.
* Checks are the only accepted form of payment. $10
fee for insufficient funds.
*Financial Assistance is available through Girl Scouts
Of Northern California. Please submit a Financial
aid form to the address listed on the form. Do not
send money with financial aid form. Do not send
financial aid form with camp registration form.
Custodial Care: Both Parents  Mother/Guardian only
Father/Guardian only Other
She is (check all that apply) American Indian or Alaskan
Native Asian Black or African American  Hawaiian or
Pacific Islander White Other (please specify)
.
I choose not to share at this time. She is Hispanic or Latina
Yes or No I choose not to share at this time
Household Income: $0-$14,999  $15,000-$34,999
$35,000-$49,000 $50,000-$74,999 $75,000-$99,999
$100,000 or more I choose not to share at this time
Important Forms
Girls attending camp must have a physical within the last year and
complete a Resident Camp Health History / Physical Form
which are available on our webpage at kampkonocti.org. Your
child must bring this form to camp. We would prefer it
returned to us prior to camp to better meet your daughter’s
needs while at camp.
Please list any special needs we should be aware of:
(Diet, physical limitations, etc.)
_______________________________________________________
_______________________________________________________
_______________________________________________________
Permission to Attend Camp
I have read all the camp information, and as a legal guardian
of this child I give permission for her to attend camp, for her
to be transported out of camp for program and other
purposes, and for emergency treatment to her in case of
injury or illness, from or during camp session.
I understand that my daughter must bring Resident Camp
Health History /Physical Form to camp, signed by a
physician, or she will be unable to attend. (Form available at
www.kampkonocti.org) I agree to cooperate with all rules
and procedures regarding camp. I give permission for my
daughter to be photographed, and for Girl Scouts of
Northern California to use those photographs for publicity
purposes.
I understand a waiver is required by Camp Navarro for my
daughter to attend Kamp Konocti. (Available on our website)
My daughter is over 12 years of age and has my permission to participate in the rifle range. Yes No
Signature:
Date: