Teen Adventure Application

ROCKFISH

CAMP & RETREAT CENTER

226 Camp Rockfish Rd., Parkton NC 28371

PLEASE PRINT CLEARLY OR TYPE: (Separate Applications Required)

Camper Name: ________________________________________________________

Phone: (_____) ____________ Age: _____________ Birthday: ___/___/____________

Full Address (Including Zip Code) __________________________________________

______________________________________________ Zip __________________

Gender: male ____ female ____ Grade completed this year ___________________

Parent/Guardian Name and Address:_________________________________________

______________________________________________________Zip ____________

Please share any information which would help us better understand this camper:

___________________________________ __________________________ __________

____________________________________ ______________________ _____________

Please select the week(s) you wish to attend:

___June 16-20 ___June 23-27 ____ June 30- July 4 ___July 7-11 ___July 14-18

Registration is required. Limited space is available so register Early!

This program is for children who are completing 6th - 8fth grade.

Deposit: A $65.00 non-refundable non-transferable deposit per week per child is expected with registration form. The deposit(s) will be deducted weekly from the total week fee. The balance ($85.00) of which is due the first day of camp.

Check #___________________Amount of Payment $______

A $25.00 FEE WILL BE CHARGED ON ALL RETURNED CHECKS

Total Cost: _____________

Basic Camp @ $150.00/week;

Total amount of deposit: ($65.00 per week) $______

Balance due: $_________

Please complete this form and return it with the required deposit, check/money order payable to Camp Rockfish send to: 226 Camp Rockfish Rd., Parkton NC 28371, for credit card payments call (910) 425-3529 . Please write the camper's name on the check and do not staple check to application. All applications must be accompanied by the appropriate deposit- No exceptions. All other forms should be completed and brought with your child the first day of camp. Please call if you have any questions. (910) 425-3529

Parents, please indicate your preference regarding photographs, videos and other facsimiles:

__I prefer that photographs, videos and other facsimiles of my child not be used in promotional or souvenir materials for camp.