Critter Camp Summer 2009 Registration
Child’s Name:___________________________________ Age:____________ Gender___________
Name to appear on camp badge ________________________________________________________
School_______________________________________ County______________________________
How did you hear about Critter Camp?__________________________________________________
Grade will be in Fall 2009 (circle one): 1-2 3-4 5-6 
Camp week(s) you will be attending (please circle):
June 22-26
July 6-10
July 13-17
August 3-7
August 10-14
My child’s t-shirt size is (please circle): child-small child-medium child-large
Adult-small adult-medium adult-large
Contact Information
Parent/Guardian Name(s)_____________________________________________________________
Mailing Address:_________________________________ City/State/Zip______________________
Home Phone___________________________ Cell/Work Phone_____________________________
Email__________________________________ Fax_____________________________________
Medical considerations: (allergies, medical conditions, physical limitations, medications, etc.)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Behavioral/Special supervision needs: (these help us in determining class staffing)
_________________________________________________________________________________
_________________________________________________________________________________
Emergency Information
Emergency Contact____________________ Relationship_______________ Phone______________
Emergency Contact____________________ Relationship_______________ Phone______________
(If Parents are not available)
In case of an accident or serious illness, I request that HHS contact me. If HHS is unable to contact me or the emergency contacts, I authorize HHS to make whatever arrangements deemed necessary. I authorize Hanover Humane Society to use my child’s name, photograph, and/or video image for education and public relations purposes unless checked below.

Signature______________________________ Relationship________________Date_____________
_____I DO NOT authorize the use of my child’s name, photograph, and/or video image.
Payment Method:
____Cash (exact change enclosed)
____ Check or Money Order made payable to Hanover Humane Society
OR
____ Credit Card
(please circle) Visa MasterCard Discover
Credit Card #_________________________________________
Expiration Date_______________________________________
Authorized signature___________________________________

Please mail completed forms to:
Hanover Humane Society
Attn: Critter Camp
12190 Washington Highway
Ashland, VA 23005
You may also register via phone by calling
804.874.2688 or by fax at 798-8251
For more information or to request a
scholarship application feel free to call
us at 874.2688