Please select term you wish to attend:
First Choice: Second Choice: Year:
Camper's Full Name: Name called or Nickname:
Camper's Date of Birth: Age: Height: Weight:
School Currently AttendingGrade to be completed by camp
Home Address
City: State: Zip:
Country: Email:
Mother's name Profession
Home Phone: Work Phone: Fax:
Father's name: Profession:
Home Phone: Work Phone: Fax:
Does Camper live with both parents? I
To whom should reports go? Is either parent deceased?
Is child affected, or likely to be affected, by any custody orders during camp session? YesNo
Church Affiliation
Can camper swim? No
What does camper want to gain most from camp?
What are parental objectives?
Heart is an active camp; all campers are expected to take part in all activities unless for medical
reasons. If there are any activities in which camper should not participate for medical reasons list:
Is there anything the counselor or camp office should know about camper? (medical, physical, emotion)
Is camper taking or likely to be taking any medications on a regular basis? Yes No
Has camper been on and stopped taking any behavior altering drugs in the last 12 months? YesNo
I recognize that there are elements of risks in the activities at Camp. I give my permission for the above named camper
to participate in and to be transported to all activities. In the event I can not be reached in a situation the camp regards
as a medical emergency, I hereby give my permission to the camp director to secure proper medical treatment,
which may include, but not limited to, hospitalization, surgery, ordering of injection, anesthesia for the person named
herein. I have read or will read, and agree to comply, to all rules and regulations of Heart O' the Hills Camp.
All fees payable to Heart O' the Hills Camp, Hunt, Texas, and for further consideration for allowing my son, or sons, to
attend Heart O' the Hills Camp for the period here to fore designated. I hereby release Si Ragsdale, individually,
Kathy C. Ragsdale, individually, Jeeper Ragsdale, individually, any staff person, consultant or clinician, and Heart O' the
Hills Camp Inc., from any damages for any personal injury or sickness, or otherwise suffered by my son, or sons,
due to any accident on or off Heart O 'the Hills premises that might occur to my daughter while enrolled at Heart O' the Hills.
Please enter name of Parent Completing this application
Please enter name of camper applicant