White Dog Farm Camp Registration

Camper’s Name __________________________________________

Parent’s Name _______________________________________

Address_____________________________________________

            Phone Number __________________________

Work Number___________________________

E-mail _________________________________

Emergency Number______________ Relationship_____________

Age ____ Grade ______

Allergies ______________________________________________

Medications and dosage___________________________________

Physician ____________________Phone#____________________

Enclosed deposit of:  $50.00

Week(s) preferred ________________

Please make checks payable to Anna Hyde.   Checks and Release Form may be mailed to :                   

Anna Hyde     685 Old Alpharetta Road     Alpharetta, GA 30005

                         Please read and sign Release Form.