260 Chestnut Ridge Road, Mount Kisco, NY 10549                                   www.westmorelandsanctuary.org
          (914)666-8448(914)242-1175                              info@westmorelandsanctuary.org
                                       Westmoreland Sanctuary Camp Registration Form 2021
         Please check off which camp(s) for which you are registering:
         Jump into Summer Camp (June 23-25) ____         Survive the Wild Camp 1 (June 28-July 1)  ____ 
         Nature Explorers Camp 1 (July 12-15) ____       Survive the Wild Camp 2 (July 26-29) ____ 
         Nature Explorers Camp 2 (August 9-12) ____ 
         Please fill out the below information:
         Child’s Name_________________________ Nickname______________ Age________ Grade________
         School Attending ___________________________________________________________________________________
         Home Address _____________________________________________________________________________________
         Parent/Guardian’s Name___________________________________ Day Time Phone ____________________________
         Cell Phone __________________ Email Address__________________________________________________________
         Alternate Emergency Contact ___________________________________ Phone ________________________________
         Person who is authorized to pick up child at the end of program_______________________________________________
         Does your child have any medical concerns? If yes, please explain.____________________________________________
         __________________________________________________________________________________________________
         Does your child have any allergies? If yes, please list._______________________________________________________
         Pediatrician name _________________________________________ Phone _______________________
         General Release: the undersigned herby releases Westmoreland Sanctuary employees, trustees, and volunteers thereof, of
         any responsibilities should an accident or injury occur to the above-named participant while on the grounds of 
         Westmoreland Sanctuary. I understand that Westmoreland may use photos taken during events unless I notify them in 
         writing. I understand I will not bring my child to camp if exhibiting flu like symptoms and follow New York State 
         quarantine guidelines.
         Parent/Guardian Signature                                       Date
         __________________________________________                      ___________________
         Payments can be made by check or by credit card on our website. www.westmorelandsanctuary.org/camps
         Jump into Summer Camp (3 half days)             Week Fee: Non-Members - $150 / Members - $120
                                                         Daily Fee: Non-Members - $50 / Members - $40
         All other camps listed on this form (4 days)    Full-Day Week Fee: Non-Members - $300 / Members - $240
                                                         Half-Day Week Fee: Non-Members - $200 / Members - $160
                                                         Full-Day Daily Fee: Non-Members - $85 / Members - $68
                                                         Half-Day Daily Fee: Non-Members - $50 / Members - $40
         Individual days attending (if not week): _________________________________________________________________________