Lee County Sheriff’s Dept. Summer Camp Registration – Summer 2015
***NEATLY complete and return with the $30 fee. Fee covers everything!
662-680-6037
Camp will be held Monday – Friday, 8am – 3pm each day. We can only accept 60 students per camp and will
do so based on first-come, first-serve basis with completed camp application and payment.
**YOU WILL BE NOTIFIED OF ACCEPTANCE
Student’s name: _________________________________
Date of birth: __________________________
Mailing address: ________________________________
School:_______________________________
________________________________
Child’s age: ____________________________
**Contact phone number(s): __________________________________________________________________
Your email address: NEATLY_____________________________________ Grade entering August 2015: _____________
Circle camp you are requesting:
________________________
________________________
June
8 - 12 @ Mooreville Elem
June 15 – 19 @ Saltillo Elem
June 22 – 26 @ Saltillo Elem
FULL
Students can attend any camp. Bus will run to/from each school each day.
EMERGENCY INFORMATION:
Parent/Guardian: __________________________________ Place of employment: ______________________
Cell phone(s): ______________________________________ Work phone: ____________________________
Additional emergency contact name(s) and phone(s): ______________________________________________
***If there are any special notes on who can/cannot pick up your child, please speak with us personally.
MEDICAL INFORMATION:
Does your child take medication? ______ If so, please list: _________________________________________
Does your child have any special medical conditions or allergies that we need to know about? _____________
If so, please list:____________________________________________________________________________
_________________________________________________________________________________________
Can your child swim? (yes or no) _______
I understand that all the rules of the summer camp must be followed in order to ensure a safe and fun time for all students
attending. I understand that any student who does not follow the rules will not be allowed to return, and payment will not be
refunded. I release the Lee County Sheriff’s Department, DARE, Lee County Schools and any/all of its agents acting on its behalf, of
any liability incurred during the activities of camp. In case of emergency, I authorize the Supervisor to make any medical decisions or
seek medical attention for my child until I can be reached. My signature provides my permission to attend all camp activities on/off
property.
I understand and have read (or have had read to me) the information above:
___________________________________________
Parent/Guardian Signature
___________________________
Date
To be completed by Staff
__
_____ $25 paid ____date ___officer initial Due to pre-payment of events, this fee is NONrefundable
30
once your child has been accepted to camp.