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One camper per application.

Camper's Name______________________________________Sex_____Date of Birth_______________

Address__________________________________City_________________State____ZIP_____________

Telephone (      )_____________________Do you own a computer?______Mac or PC (circle one)

TOTAL ENCLOSED $__________ (Payments are non-refundable due to limited spaces available.)
Make check or money order payable to "La Plaza Telecommunity." Cash or Credit Card payments must be presented in person.
________________________________________________________________________________
PARENTS, PLEASE READ THE FOLLOWING AND SIGN BELOW.

1.The camp is not responsible for personal belongings lost or damaged by casualty, loss, theft, etc. The camp has the right to dismiss any individual if their actions or attitudes are detrimental to the best interests of the camp. No refunds will be given upon such dismissal. Camper's parents will be assessed for facilities damaged due to negligence of camper.

2.In case of illness or accident, the camper's parent(s) will be notified immediately. It will be the responsibility of the camper's parent(s) to transport the camper for medical care. In case of an emergency, the camp will ensure the camper receives immediate and competent care. All such expenses will be billed to the camper's medical plan and parent(s).

Please list any dietary constrictions:_______________________________________________________

I give the camp directors permission to take my child on a field trip to Kit Carson Park and the Plaza without further notice or consent from me and to use at their discretion, photos taken at camp.

______________________________________________________Relation_________________________
Signature of parent or legal guardian of camper named above

Date_______________________________________

Total Enclosed $____________

(Please pay by check or money order. DO NOT SEND CASH.)