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SUMMER HISTORY CAMP
PERMISSION SLIP
AGES 8-11

Pamplin Historical Park will offer a history camp, Farm Fields and Battlefields: Exploring Life During the Civil War, on the following dates: June 17-19, June 24-26, July 8-10, July 15-17, July 29-31, August 5-7, 2008. The camp is designed for children between 8 years of age (must be 8 on the first day of camp) and 11 years of age, and will last from 9:00 a.m. to 4:30 p.m. The cost is $100.00 for the full three-day session. The payment covers registration, materials, tee-shirt, kepi, harmonica, crafts and snacks.

In signing this form, I hereby indicate my permission for the following named child, for whom I am the legal guardian, to participate in the Pamplin Historical Park history camp program. I further state that the child does not suffer from any medical condition or disability that may require special attention or care, unless indicated on the attached application and arrangements have been made to provide the necessary care.

In permitting my child’s participation in the history camp, I hereby agree and hold harmless Pamplin Historical Park, its officers, employees, and agents from any and all liability. I further understand that Pamplin Historical Park reserves the right to remove a repeatedly disruptive child from the program, and that the admission fees are non-refundable.

Name of Child Child’s Birthdate
Name of Legal Guardian  
 
Address of Guardian City, State Zip
Daytime Phone Number of Guardian  
 
Emergency Contact (other than Guardian) Phone


Signature of Legal Guardian_______________________________________________________

Date of History Camp
June 17-19 June 24-26
July 8-10 July 15-17
July 29-31 August 5-7

Is this your first camp? Y N
If no, how many camps have you attended?
Name on card
CC #
Expiration Date


Signature_____________________________________________________________________

*******************************************************Office Use*****************************************
   
Date Received Amount Received
_______________________________________ __________________________________
   

 

Print this form, and FAX or mail it to us with your medical and photo release forms at:

Pamplin Historical Park
6125 Boydton Plank Road
Petersburg, VA 23803
( 804) 861-2820

 
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