Camper's First Name  * Nickname
Camper's Last Name  * Age  on June 1st
Date of Birth  * (eg. 05/21/1970)  
Grade Completed by Camp Opening
Previous Camping Experience
Parent 1 Name  *
Home Phone  *
Cell Phone  *
Address  *
City  *
State  *
Zip  *
Country
Work Phone  *
Occupation
Primary E-mail for contact  *
Parent 2 Name
Home Phone Same Other
Cell Phone
If Same Address click here. Other
Address
City
State
Zip
Country
Work Phone
Occupation
Secondary E-mail

2012 Camp Sessions

 Tuition
Season Session...... Sun., June 24 to Sat., Aug. 11, 2012..... $6,700
Five week Session... Sun., July 8 to Sat., Aug. 11, 2012...... $5,600
Four week Session...... Sun., June 24 to Sat., July 21, 2012...... $4,500
Three week Session... Sun., July 22 to Sat., Aug. 11, 2012...... $2,950
1st two week Session... Sun., June 24 to Sat., July 7, 2012...... $2,600
2nd two week Session... Sun., July 8 to Sat., July 21, 2012...... $2,600
Camper lives with Mother Father Stepmother Stepfather Other
   CUSTODY Please explain the custody arrangements if applicable
   
In case of emergency, if the Director is unable to reach the family, call
Name Address
Relationship to camper City
Home Phone State
Cell Country
   If parents have a summer address or will be travelling, please forward dated itinerary to camp office.
Instruction in horseback riding (English saddle) is offered at additional cost.
Camper opts for instruction in riding Yes No
If yes, how often? Six times per week Three times per week
If qualified, is permission given to jump? Yes No
Camper's Personal Record
Camper's name:
Camper's email: School:
Cabin mate requests. Limit to two names, listed in order of preference (requests are not guaranteed)
1:   2: 
Is camper a second or third generation camper of Camp Netimus and/or Camp Shohola?
Yes No
 
   If yes, name of alumna/alumni:  
 
Address : Phone :
Comment on any special needs your daughter may have (health, diet, behavior, etc.)
 
Comment on any concerns or requirements regarding your daughter (trips, store/canteen, tutoring and activities)
 
Do you have a son at Camp Shohola? No Yes Son's Name : Session :
     
May we use your name and contact information as a reference for prospective campers? Yes No
May we donate the refund from your daughter's spending allowance to the Netimus Tuition Assistance Program? Yes No
 I first heard about Camp Netimus
Friend/Relative
Referral/Agency
Internet
Other
Camp Fair
Mailing/Email
Advertisement
   
 
 
 Please list below the names and addresses of parents who might be interested in receiving information about Camp Netimus
Parents name
Camper/Age
Address
City/State/Zip
Country
E-mail
Parents name
Camper/Age
Address
City/State/Zip
Country
E-mail
CAMP AGREEMENT
The directors reserve the right to request the withdrawal of any girl if it seems necessary for the welfare of the camp. Should this become necessary, no camp fees will be refunded. I give permission for photographs, videotapes, or interviews to be published and used to illustrate, report, promote and advertise the camp. Use of any such photographs, videotapes, or interviews may include, but is not limited to, use of the photographs, videotapes and interviews on Internet web sites promoting or reporting on the camp. I further give permission for my daughter to participate in camp activities and trips. I hereby give permission to the medical personal selected by the camp director to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment including hospitalization for the person named above. I further assume all risk of and hold harmless and do hereby release, discharge Camp Netimus, Inc., its directors, officers, agents and employees from and against all liability for loss, damage, injury, or illness to the camper or his/her property relating to or deriving from his/her presence at or travel to or from Camp Netimus Inc. from whatever cause except for gross negligence or willful misconduct.

I Agree to the term of enrollment and regulations of the camp as stated on this application.
 
Parent(s) Initials * Date

After receiving this application and the $750.00 deposit, Camp Netimus will begin sending you additional information and required forms for summer.
Please indicate to us how you would like to receive this correspondence:
  Hard Copy / Snail mail   Email   Download: www.Netimus.com

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