Coutts Winter Camp 2026 Registration Form

Mail this completed form and payment to: PO Box 565 Derby VT 05829

 

 

Campers Name __________________________________ Age _____  Phone_________________________

 

Parent/guardian Name______________________________Address_______________________________________

 

Cost $150 all four days or pay by the day at $45/day               Drop off 8:30-8:45 pickup 3:45-4pm

 

Mark the days they will be attending:

 

___ Monday-Thursday, all 4 days Feb 23-26

___ Monday Feb 23rd

___ Tuesday Feb 24th

___ Wednesday Feb 25th

___ Thursday Feb 26th

 

In the event of a life-threatening emergency, 911 will be notified immediately. For non-life-threatening conditions, the parent/guardian listed above will be called first. In case a time comes when the parent/guardian is unavailable, please provide two emergency contacts that can be reached during the week. If an emergency contract cannot be reached and we believe an Emergency Room visit is required for a non-life-threatening emergency, Coutts may transport campers to North Country Hospital.

Emergency contact 1                                                              Emergency contact 2

Name ___________________________________.               Name ________________________________

 

Phone ______________relation to camper __________     Phone _______________relation to camper _________

 

Does your child have any medical conditions, allergies, special concerns, etc., that Coutts should be aware of?

__________________________________________________________________________________________

 

__________________________________________________________________________________________

 

Health Insurance Company ________________________________________________________________

 

Policy # ________________________ Policy Holder ____________________________________________

 

____I hereby authorize Coutts-Moriarty Camp or its representatives to photograph or video my child for marketing use.

 

Medications you authorize Coutts to provide to your child as needed:  ___ Tylenol ___ Benadryl ___ ibuprofen

 

_____________________________________________________________

Parent/guardian signature & date

 

Mail payment and this form to PO Box 565 Derby, VT 05829       programs@siskinea.org     (802)673-5638