]> /Office use only:/ Date rec'd___________, check amount___________, check #__________, Notes: -Registration: Not Back to School Camp, 2003- Please fill out neatly in ink or type. Return to Genius Tribe, P.O. Box 1014, Eugene, OR 97440, or fax to 509-696-3310. Each camper must have his/her own registration form--do feel free to make photocopies; don't put siblings or friends on the same form. You must enclose a $75 NON-REFUNDABLE deposit with this registration for each session you want to attend, checks made out to Genius Tribe. We accept checks and money orders only; no credit cards; U.S. funds only. Your deposit will be refunded in the event that your session of camp is canceled or if it is full before you register, but not necessarily for any other reason. (See "about refunds" in the brochure.) The balance of your camp fee is due 6 weeks before the start of camp (July 14, July 24, or August 14), after which a $25 late fee applies. If all money is not in one month before the start of camp, you will be dropped from our roster. Except in unusual circumstances, there are no refunds of any amounts paid, after 6 weeks before the start of camp, so if you're going to cancel your registration you'd best do it before then. If your registration is postmarked by March 18, 2003, your total cost is $485; after that, the total cost is $510. We will send an acknowledgement within 2 weeks of receiving your registration, confirming which session you are registered for, how much money we have received, and how much money you will be paying total. If you don't hear from us within a month of mailing your registration, please contact us to make sure we got it. We suggest you make a copy of this form after filling it out. Circle the session(s) you are registering for: Session 1 (8/25-9/1) Session 2 (9/4-11) Session 3 (West Virginia, 9/25-10/2) If your first choice session is already full, would you like to register for another session? Which? _________ IMPORTANT: If you are registering for Session 2, you must also fill out the new Session 2 application. If Session 2 is your backup choice and your first choice session is already full, we will contact you to ask you to fill out the Session 2 application. Your legal name (first/last): _________________________________________ Preferred name or nickname if different: _______________________ Daytime phone________________________ Your birthdate (month, day, year):__________________________________ Your gender ___F ___M Complete mailing address with zip/postal code/country if not U.S.: _______________________________________________________ _______________________________________________________ _______________________________________________________ e-mail address:____________________________________ Can we send your confirmation by email rather than snail mail? __________ Parent/guardian name(s) (first/last) and address(es) if different from above: _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ Name 2 other people to contact in case of emergency. (We will attempt to contact parents/guardians first unless you request otherwise. If unable to reach parents/guardians, we'll contact the first person listed below, and if we reach her/him, we won't contact anyone else unless you request that clearly in the space below.) 1st choice--name and relationship to you: ___________________________________________ Daytime phone: _____________________________________ Evening phone:__________________________________ 2nd choice--name and relationship to you: ___________________________________________ Daytime phone: _____________________________________ Evening phone:__________________________________ If this is your first time at camp: Why do you want to attend NBTSC? What do you expect to get out of it? Circle any of the following foods you do not eat (meat will not be served, and white sugar and caffeine are generally not served either). dairy products (milk, cheese, butter etc.) eggs wheat Do you have any medical conditions or physical limitations that you'd like all staff to be aware of? (You will also be required to fill out a medical history form, which you'll receive later. The information here will be shared with all of the senior staff; information on the medical history form will only be shared with staff if it seems necessary for campers' well being.) What, if anything, would you like us to do to help you deal with this condition(s)? Can we share your name/address/phone# with other campers? In late spring or early summer we will send out a directory of campers to enable you to hook up with each other for travel arrangements. May we include your name, phone number, and address on this list, and also in the directory which all campers receive at camp? (Inclusion in the travel directory does not obligate you to make plans with others; it does help leave your options open, and you may be able to save a great deal of money by arranging carpools.) ____yes _____no If yes, do you want to add a brief note to your travel directory listing? (i.e. "planning to drive, looking for riders West of Mississippi" or "hoping to find carpool" or "looking for Greyhound travel buddies")? Would your family like to be listed in this year's travel directory and camp directory as a "NBTSC host family?" This means you would be willing to have, as a houseguest, pretty much anyone from any session of camp, or next year's camp-not just your personal friends. (Only during times that are convenient for your family, of course.) Be sure to talk with your parents before saying "yes" to this one. Would you like to be listed in the travel directory as a person who would like a pen-pal (email or snail mail) before camp? Money: Please check one of the following. ________My registration is postmarked before March 18. I will pay a total of $485 per session. ________My registration is postmarked after March 18. I will pay a total of $510 per session. Scholarship Fund: I am also enclosing a tax-deductible check in the amount of _________ made out to the Self Education Fund, to help provide scholarships for people who can't afford camp. (Make sure you write "NBTSC scholarship fund" in your memo line.) For people applying for scholarships and work-trades-please answer this question carefully: (If you check yes, we will hold a spot for you at NBTSC but will not refund your deposit unless we give you a worktrade position. If you check no, we will refund your deposit if we can't give you a worktrade position or scholarship, BUT we can't necessarily guarantee you a spot at NBTSC if you later change your mind and want to come as a full- price camper. Camp did not completely fill up in 2002, so this may be a moot point, but in previous years we have been full, with a waiting list, in early spring.) I will attend NBTSC whether or not I receive a scholarship/work trade: ______yes ______no. Note to everybody: In May or June we'll send you a camp handbook, a more detailed questionnaire, and will also request that you send 2 photos and a description of yourself. This will help the staff get to know you a little bit before camp, so we can make the most of our week together. We'll ask (among other things) what workshop, sport, or other activities you might be interested in leading or co-leading. You might want to start thinking about it now. If you've been to Camp Myrtlewood previously: do you have any ideas for a service project that a small or large group of campers could contribute to Camp Myrtlewood while we're there? Here's the stuff you gotta sign: I have read all of the accompanying information on Not Back to School Camp, and I am choosing to attend by my own free will. No parent, guardian, or other person is coercing me into attending. All of the information provided above is accurate and complete to the best of my knowledge. I agree to abide by the rules set by the camp staff, and to contribute to the camp by performing chores as needed and by sharing my unique skills and creativity. I understand that there will probably be no nurse or other medical personnel on the premises, but that if anyone has a medical emergency she or he will be sent via ambulance to a hospital. (Camp Myrtlewood and Buffalo Gap provide insurance for injuries that take place on their premises.) I will be as responsible as possible for my own health and well- being, and notify staff immediately if I have a health or other problem which needs attention. I understand that if I violate camp rules repeatedly, or in any way that the staff considers seriously threatening to others' camp experiences, I will be sent home immediately at my own expense. I promise to do my best to have a great time and to help everyone else have a great time too. I also understand that my deposit is non- refundable if I later choose not to attend camp (unless camp is full before this registration is received), and that NBTSC reserves the right to make absolutely no refunds for any reason of any camp fees after July 14 (1st session), July 24 (2nd session), or August 14 (3rd session) (unless camp is canceled). If I have a contagious disease before the start of camp, I will notify camp staff. (I understand that I may be asked not to come, in which case all but $40 of my fees will be refunded; a statement from a healthcare provider may be required for a refund.) And, I understand that I cannot attend camp if I do not complete and return the required forms before the beginning of camp. Signature __________________________________________ Date ___________ Parent/guardian statement (required for campers under age 18-both parents sign if possible, please): I also agree to the above statement signed by my son or daughter. In addition: I have read all of the accompanying information on Not Back to School Camp, including "what parents should know about NBTSC" and "an important note for parents and campers on bedtimes and sleeping arrangements." My son/daughter is attending camp by her/his own free will and is not being coerced into doing so by me. I understand that insurance is provided for physical injuries that take place on camp premises, but I agree to be responsible for any emergency or medical expenses not covered by this insurance. I understand that if my son/daughter violates camp rules repeatedly, or in any way that the staff considers seriously threatening to others' camp experiences, he/she will be sent home immediately and I will be billed for that expense.^1^ I agree to reimburse Grace Llewellyn for any expenses incurred in such an event. Signature __________________________________________ Date ___________ Signature __________________________________________ Date ___________ [1] In the unlikely event that we do need to send someone home, we'll attempt to phone parents first to discuss travel plans, but Camp Myrtlewood and Buffalo Gap are remote and we may need to simply drive to the closest Greyhound bus station. If for some reason we can't reach a parent or anyone listed as an emergency contact, we'll go ahead anyway, most likely with a Greyhound bus ticket.