CAMP NAKANAWA

1 CAMP NAKANAWA . 1084 Camp NAKANAWA Road ~ Crossville, Tennessee 38571-2146. (931) 277-3711 ~ FAX (931) 277-5552. Please Attach Office e-mail: Recent Photo Web Site: (information, pictures, newsletters). Camper e-mail address: (put name, camp & cabin # in subject line). Ann & Pepe Perron: Directors Please enroll my daughter as a member of: Two Week Session: June 16- June 29, 2019 Four Week Session: July 1 July 28, 2019. $ $ __ Junior 8-11 years (Completed Grades 2-5) __Junior 8-12 years (Completed Grades 2-6). __Intermediate 11-14 years (Completed Grades 6-8)__Intermediate 13-14 years (Completed Grades 7-8).

2 __Senior 15-17 years (Completed Grades 9-11). The Registration Fee of $400 2WK/$450 4WK accompanies this application. In making request for enrollment, my daughter promises to be a loyal camper, to uphold the ideals of NAKANAWA , and to be an integral part of NAKANAWA for the entire session. Camper's Name:_____. (First) (Middle) (Last). (Please underline name camper wishes to be called) Camper's e-mail address:_____. Street Address:_____Home Telephone:_____. City:_____State:_____Zip Code:_____. FAX Number:_____ Parent's e-mail address:_____. Date of Birth:_____Height:_____Weight:_____Soc. Sec.

3 #_____Age:_____. Please include copy of Insurance Card, front and back, & policy holder's SS# and Birthdate. School Attending:_____Grade completed as of June 2018:____. Number of Years at NAKANAWA :2wk____4wk____Team:A__V__Other Camps Attended_____. Through whom did you learn of NAKANAWA ?(name please)_____. Religious Preference:_____If Catholic, will your daughter attend Mass? Yes No Are Parents Divorced, Separated or Either Parent Deceased?_____. If so, with whom do you reside?_____Relationship:_____. Brother(s) & Sister(s) Names & Ages:_____. Mother's Name:_____Occupation:_____. Home Address, if different:_____Work Telephone:_____.

4 Cell Phone or any other Emergency Number:_____. Father's Name:_____Occupation:_____. Home Address, if different:_____Work Telephone:_____. Cell Phone or any other Emergency Number:_____. Mail Billing to:_____. Send Weekly Newsletters by e-mail to:(address)_____. Is Mother or Grandmother a Former NAKANAWA Camper or Counselor?_____Years:_____. Maiden Name(s)-First & Last:_____Team(s):_____. Is Sister a Current/Former Camper?___Name:_____Team:_____. Activities to be Encouraged:_____. Activities to be Restricted:_____. Advance notice by May 1st for acceptance of modified menu/Doctor's orders required: Please specify any special dietary needs:_____.

5 Please specify any daily medications:_____. Please specify any severe allergies:_____. T-Shirt size (circle one) YS YM YL S M L XL XXL. Please read carefully. The following must be signed to complete application. 1. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Camp Directors to hospitalize and/or treat my child and agree that I will be financially responsible for any charges for services provided by medical professional for any accident, injury, or illness incurred while enrolled at Camp NAKANAWA . 2. I give permission for photographs or video footage of my daughter to be used by the camp for promotional purposes.

6 3. All activities at Camp NAKANAWA , Inc. are supervised by competent personnel with every precaution exercised for the safety of the campers and staff. However, Camp NAKANAWA , Inc., cannot be responsible for accidents or incidents which may occur in any activity. 4. Camp NAKANAWA , Inc., cannot be responsible for accidents or incidents which may occur in activities or field trips that take place outside of camp facilities located in Mayland, Tennessee. 5. If a camper chooses to leave the camp session early, she is allowed to return to camp as a visitor, but not as a camper, unless prior arrangements have been made with the directors.

7 6. This application is made with my consent and approval of the conditions listed here and in the catalog, and I hereby certify that my child is of good moral character. She has my permission to engage in all prescribed activities, except as noted by me above. Signature:_____Date:_____. Please share information concerning your daughter that you feel would be helpful in making her camping experience a success. Also, please express any special desires you have for your daughter and what you expect her to gain from _____. _____. _____. Cabin Mate Request (limit 2): 1_____2_____. REFERALS-Please send information about NAKANAWA to the following prospective camper: 1.

8 Name:_____Age:_____. Parent's Name:_____. Address:_____. 2. Name:_____Age:_____. Parent's Name:_____. Address:_____. THE CAMP FEE IS SUGGESTED TO BE PAYABLE AS FOLLOWS: TWO WEEK CAMP - TUITION: $ SUNDAY, JUNE 16TH SATURDAY, JUNE 29TH, 2019. Registration Fee $ First Payment February 1st $ Final Payment April 1st .. $ FOUR WEEK CAMP - TUITION: ..$ MONDAY, JULY 1ST SUNDAY, JULY 28TH, 2019. Registration Fee $ First Payment February 1st $ Final Payment April 1st . $ Rental Linens (International Campers Only) $ TO BE ENROLLED, COMPLETED REGISTRATION FORM (& PICTURE) MUST BE ACCOMPANIED BY THE REGISTRATION FEE.

9 PARTIAL REFUND OF REGISTRATION FEE WILL BE GRANTED IF CANCELLATION IS MADE PRIOR TO MARCH 1 ST. KEEP THIS PAGE CAMP NAKANAWA CENTENNIAL SEASON. 1084 Camp NAKANAWA Road ~ Crossville, Tennessee 38571-2146. (931)-277-3711 ~ FAX (931)-277-5552. Office e-mail address: Web Site: (information, pictures & newsletters) (user name: red ~ password: blue). Camper e-mail address: (put name, camp & cabin # in subject line). 2019 GENERAL INFORMATION. TWO WEEK CAMP - TUITION: .. $ FOUR WEEK CAMP - TUITION: $ SUNDAY, JUNE 16TH SATURDAY, JUNE 29TH, 2019 MONDAY, JULY 1ST SUNDAY, JULY 28TH, 2019. Registration Fee.

10 $ Registration Fee $ First Suggested Payment February 1st .$ First Suggested Payment February 1st ..$ Second Suggested Payment April 1st ..$ Second Suggested Payment April 1st . $ Rental Linens (International Campers Only) ..$ ARRIVAL By Car with parent between 1PM and 4PM 6/16 or 7/1. Tent Row may arrive 6/29 at 2PM. By Plane:see Transportation below. TUITION The tuition fee covers all normal expenditures: board, lodging, laundry, transportation from and to the Nashville Airport, special trips, equipment in all activities, instruction and supervision by a staff of competent counselors, and also the services of the Camp Infirmary including our camp physician.