Camper Application

Please select term you wish to attend: 
First Choice: Select First Choice TermMini Term1st Regular Term (4 weeks)2nd Regular Term (4 weeks)Summer Term (5 weeks)Summer Term (8 weeks)  Second Choice: Select Second Choice TermMini Term1st Regular Term (4 weeks)2nd Regular Term (4 weeks)Summer Term (5 weeks)Summer Term (8 weeks) Year:  Select Year2007200820092010

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?  YesNo  If not with whom?

	To whom should reports go?      Is either parent deceased?  NoYes  

Is child affected, or likely to be affected, by any custody orders during camp session? YesNo

Church Affiliation  Where did you learn about Heart? (Be Specific)



Family members who have attended The Heart? Names and approximate years



Other camps previously attended and dates: 

Can camper swim? Play Musical Instrument? YesNo If yes, what? 

Names and ages of siblings:

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.
I agree to the terms above:   Yes   No 

         Please enter name of Parent Completing this application

	Please enter name of  camper applicant 

$500. Deposit may be charged to:             or call (830) 238-4650 VISA MASTERCARD DISCOVER AMERICAN EXPRESS                        or fax (830) 238-4067 Account #: Expiration Date:    Security code: Name of Card Holder:

Deposit of $500 must accompany application. 80% of Deposit Refundable upon request by written correspondence until March 1 of year applied for. Deposits non-refundable after March 1

Please print this form and mail to the address above. Thank you.
 
   N
back to index