Livi

ng W

ater

s M

inis

trie

s10

451

Ash

craf

t Rd.

Del

evan

, NY

140

42

S U M M E R 2 0 1 7

July 3-Aug. 5 / $305 / Ages 8-18 Fun-filled, wildly adventurous weeks with new games and experiences that are sure to be a blast!

SUmMErweeks

Non

-Pro

fit O

rg.

U.S

. Pos

tage

PAID

Per

mit

No.

399

7B

uffa

lo N

Y

Our theme this year is

“Fearless” based on

2 Timothy 1:7. We want

to live our lives showing

love, not fear. There is

a better way to live than

fear, and Jesus came to

show us what it was all

about! With Him we can

live our lives without fear,

by being motivated by

His love!

YOu do’Nt wanT to M

iSs ThiS.

iT s YOur SUMmeR...

mAke it Fe arLeS

s.

WWW.C IRCL ECRANCH.ORG

familyCAMPAugust 11-13 A great weekend to have family adventures and make memories that will last a life time!! This one packs out quick, so don’t delay!!

If you want any more information you can check out our website (above) or you can download our app for your smart phone!

L i Fe iS GooD oN the Ranch.

June 27-July 2 / $305 / Ages 12+ Teen week is a wild adventure designed just for our teen campers. This year we will be having Circle C Has Talent: The Ultimate Lipsync Battle! You and your cabin will produce and perform an epic lipsync production as part of our competition. You will also be featured in our camp movie, complete with a premiere!

EXpREsSweek T EENweekJune 21-24 / $150 / Ages 8-18

A half week for all ages that is jam packed with as much fun and adventure as we could cram into it!

2017 CAMPER REGISTRATION & MEDICAL FORM(Please complete all information & type or print clearly)

Child’s Name ____________________________________________________________________________________________

Address ________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip _______________

E-Mail _________________________________________________________________________________________________

Date of Birth ____ /____ /_________ Sex o F o M Age ___ Weight ________ Current Grade Level ________________

I prefer to bunk with ________________________________________________ (bunk mates must be within one year of the same age)

Emergency Contacts

Home Phone Cell Phone Work Phone

FATHER’S NAME

MOTHER’S NAME

GUARDIAN

OTHER CONTACT

MEDICAL FORM Insurance Information: Name of Insurance Company: _________________________________________________________________________________

ID# _______________________________________________ Group # _____________________________________________

Policy# ____________________________________________ Certificate# ___________________________________________

Name Of Camper’s Physician: _____________________________ Phone #: ____________________________________________

Date of last Physical____/____/______

2017 FAMILY WEEKEND (August 12-14) REGISTRATION FORM (please type or print)

Adults: Ages 12 and up - $65.00 per person | Child: Ages 5-11 - $35.00 per person | * 4 years of age and under - FREEThis price includes a snack, 5 meals, 2 nights of lodging, and all the activities.

ADULTSName ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

CHILDREN:Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Address _________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip ________________

Phone:(____) _______________________________________ Cell (____) ___________________________________________

E-Mail __________________________________________________________________________________________________

There is a $50.00 (non-refundable) deposit to be sent in with the registration to reserve your unit. Registration begins at 7:00 PM Friday night in Miss Kate’s Place. (32 units available) and the weekend ends after lunch on Sunday.

Send registration to: Circle C Ranch, 10451 Ashcraft Rd. | We accept VISA, Mastercard, and Discover as forms of payment. Delevan, NY 14042

For Office Use Only

RF_________________________________ PC_________________________________ DIS_________________________________

HF_________________________________ SC_________________________________ OB_________________________________

DUE________________________________ BK_________________________________

Health History: Check if any apply & explain. Use separate paper if necessaryo Diabetes o Seizures &/or Epilepsy o Heart defect/disorder

o Bedwetting o Emotional/Behavioral Disorder o Asthma

o Hay Fever o Bleeding/Clotting Disorder o Frequent Ear Infections

o Other:(specify) _________________________________________

Any Specific Activities to be Restricted __________________________

** ALLERGIES: (Explain reaction as well) Bees or Insect Bites/Stings ___________________________________

Foods (Specify) ___________________________________________

Other (Specify) ___________________________________________

Carries Epipen: ___________________________________________ /Or Inhaler: _____________________________________________

Penicillin: _______________________________________________Immunization History: Actual dates required by NYS Health Department up to age 21, A new copy is required each camp year. Photocopies are preferred.DPT _______ /______/_______/_____ Last Tetanus

Poliomyelitis______/______/_______ MMR_________/

Influenza B _________________ Hepatitis B ____________________

Varicella_______ Chicken Pox _________ Other _________________

The following standard over-the-counter medications are available at the nurse’s office and will be administered as needed at the discretion of an RN, ONLY if approval is indicated by the camper’s health care provider. Without this signature, the camper cannot be given any of these medications under New York State Law.

Drug Name Route Dr.’s Order CommentsCircle preferred formulation(s) Check one

Tylenol Chewable tablet / elixir oYes oNo Pain or Fever > _____ºFIbuprofen Chewable tablet / suspension oYes oNo Pain or Fever > _____ºF

Robitussin Cough & Cold Syrup oYes oNoPepto Bismol Liquid / chewable tablet oYes oNo For diarrhea, upset stomach

Benadryl Chewable tabs or pills oYes oNo Allergic reactionsOther oYes oNo

Health Care Provider’s Signature: __________________________________________

Parent or Guardian ______________________________________ Date __________

(Mr., Mrs., or Reverend)

Notarized: Sworn to me this _______ day of _______________, 20 ______.

Parent’s authorization for those under 18 years of age: In the event I cannot be reached in an emergency I hereby give permission to the physician selected by the camp to hospitalize, secure treatment and order injection, anaesthesia or surgery for my child as named above.* Our local hospitals, for immediate and efficient care in case of emergency, have requested that the Parent’s signature be notarized.

*The registration fee must be sent in with the Registration form in order to be fully Registered. The balance is to be paid on arrival at camp. Money must be in US currency- No Canadian cheques (checks).Camp is filled on a first come, first served basis. It is easierthat you make sure your friend registers at the

same time if you want to bunk together. **PLEASE NOTE: In the event of sickness or illness while at camp, the Parent/Guardian is responsible for all medical expenses incurred under the authori-zation of the Camp Registered Nurse and/or Director. These Claims may be submitted to your insurance provider when eligible for reimbursement.

****In the event of injury or accident while at camp, claims should be submit-ted to your insurance provider. Our camper insurance coverage (accidents or injury only) will be reimbursed you for medical claims which exceed the amount of your personal insurance plan provisions.

METHOD OF PAYMENT Do NOT send cash or checks,

Acceptable Methods of Payment: o Money Order (payable to Circle C Ranch)

Credit Card: o MasterCard o Visa o Discover o Phoned in Payment Total amount being paid $___________

Account Number ________________________________________________ Expiration Date ______________ Security Code _______

Signature ________________________________________________ Print Name ______________________________________

DISCOUNTS!Early Bird: If your registration is postmarked by May 1 you save $20 off your week at camp (Registration fee remains $75). If you’re too late, you can still save $10 by having your registration postmarked by June 1 (Registration fee remains $75).

Extra Week: Pay full price for your first week of camp and every other week you come you get $100 off!

Sibling Discount: When you pay full price for your first child ($305) you get $50 off your second child. If you have a big family, for every sibling after the first two you get $75 dollars off a piece! This discount is for immediate family members only, and cannot be used by cousins, nieces or nephews.

COSTS: Express Week: $75.00 plus $75 non-refundable registration fee. Total $150.00 (U.S. funds) Teen Week / Circle C Has Talent: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds) Regular Weeks Three-Seven: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds)

NOTE: NY State Law requires for horseback riding: 1. Shoes with heels. 2. Helmets (you may bring your own if it is Pony Club Approved)

TWO WAYS TO REGISTER: 1. Mail in the Registration Form and completed Health History with your

$75 registration fee to this address: Living Waters Circle C Ranch 10451 Ashcraft Rd., Delevan, NY 14042-9664 OR

2. Phone in your Registration information to our office and use a credit card (VISA, MASTERCARD, or DISCOVER) for payment of your $75 registration fee. Then, mail in your completed Registration Form and Health History to the above camp address. *We MUST receive this

within two weeks of your phone-in Registration. If we do not, your reservation will be cancelled. (The registration fee is nonrefundable.)

CONTACT INFORMATION: Phone Number (716) 492-3687 or 1-800-231-6866 Fax (716) 492-1361 E-mail: info@circlecranch.org Visit our website: www.circlecranch.org Office Hours: Monday-Friday 9-5 Messages taken by phone on off-hours are not guaranteed.

WHAT TO PACK: Upon receipt of your completed registration information, we will send you “Your Official Circle C Ranch ‘Get Ready for Camp’ checklist” along with your confirmation information.We are not responsible for lost articles

The Public Health Law Requires: 1. The camp be licensed by the NYS Dept. of Health 2. The camp to be inspected twice yearly 3. The inspection reports concerning the camp are filed with the Dept. of Health, 302, Laurens St., Olean, NY.

Rules for acceptance and participation in the program are the same for everyone without regard to race, color, or national origin. Any person who believes he/she has been discriminated against in any USDA-related activity should write immediately to the Secretary of Agriculture, Washington, DC 20250

Please indicate week attending:o Express Week $150/June 21-24

o Teen Week $305/June 26-July 1/Circle C’s Got Talent

o Week Three $305/July 3-8

o Week Four $305/July 10-15

o Week Five $305/July 17-22

o Week Six $305/July 24 – 29

o Week 7 $305/July 31-August 5

Must be checked to be registered. o Special Cookout $7.00

Prescription Route DosageSchedule & Indications

Comments

NOTARY SEAL

Every week of camp includes: Horseback riding, Lasertron, Rock wall climbing, Swimming, 60’ X 250’ giant slip-n-slide, Game room, Storm the Fort, Wild games and so much more!

Livi

ng W

ater

s M

inis

trie

s10

451

Ash

craf

t Rd.

Del

evan

, NY

140

42

S U M M E R 2 0 1 7

July 3-Aug. 5 / $305 / Ages 8-18 Fun-filled, wildly adventurous weeks with new games and experiences that are sure to be a blast!

SUmMErweeks

Non

-Pro

fit O

rg.

U.S

. Pos

tage

PAID

Per

mit

No.

399

7B

uffa

lo N

Y

Our theme this year is

“Fearless” based on

2 Timothy 1:7. We want

to live our lives showing

love, not fear. There is

a better way to live than

fear, and Jesus came to

show us what it was all

about! With Him we can

live our lives without fear,

by being motivated by

His love!

YOu do’Nt wanT to M

iSs ThiS.

iT s YOur SUMmeR...

mAke it Fe arLeS

s.

WWW.C IRCL ECRANCH.ORG

familyCAMPAugust 11-13 A great weekend to have family adventures and make memories that will last a life time!! This one packs out quick, so don’t delay!!

If you want any more information you can check out our website (above) or you can download our app for your smart phone!

L i Fe iS GooD oN the Ranch.

June 27-July 2 / $305 / Ages 12+ Teen week is a wild adventure designed just for our teen campers. This year we will be having Circle C Has Talent: The Ultimate Lipsync Battle! You and your cabin will produce and perform an epic lipsync production as part of our competition. You will also be featured in our camp movie, complete with a premiere!

EXpREsSweek T EENweekJune 21-24 / $150 / Ages 8-18

A half week for all ages that is jam packed with as much fun and adventure as we could cram into it!

2017 CAMPER REGISTRATION & MEDICAL FORM(Please complete all information & type or print clearly)

Child’s Name ____________________________________________________________________________________________

Address ________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip _______________

E-Mail _________________________________________________________________________________________________

Date of Birth ____ /____ /_________ Sex o F o M Age ___ Weight ________ Current Grade Level ________________

I prefer to bunk with ________________________________________________ (bunk mates must be within one year of the same age)

Emergency Contacts

Home Phone Cell Phone Work Phone

FATHER’S NAME

MOTHER’S NAME

GUARDIAN

OTHER CONTACT

MEDICAL FORM Insurance Information: Name of Insurance Company: _________________________________________________________________________________

ID# _______________________________________________ Group # _____________________________________________

Policy# ____________________________________________ Certificate# ___________________________________________

Name Of Camper’s Physician: _____________________________ Phone #: ____________________________________________

Date of last Physical____/____/______

2017 FAMILY WEEKEND (August 12-14) REGISTRATION FORM (please type or print)

Adults: Ages 12 and up - $65.00 per person | Child: Ages 5-11 - $35.00 per person | * 4 years of age and under - FREEThis price includes a snack, 5 meals, 2 nights of lodging, and all the activities.

ADULTSName ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

CHILDREN:Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Address _________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip ________________

Phone:(____) _______________________________________ Cell (____) ___________________________________________

E-Mail __________________________________________________________________________________________________

There is a $50.00 (non-refundable) deposit to be sent in with the registration to reserve your unit. Registration begins at 7:00 PM Friday night in Miss Kate’s Place. (32 units available) and the weekend ends after lunch on Sunday.

Send registration to: Circle C Ranch, 10451 Ashcraft Rd. | We accept VISA, Mastercard, and Discover as forms of payment. Delevan, NY 14042

For Office Use Only

RF_________________________________ PC_________________________________ DIS_________________________________

HF_________________________________ SC_________________________________ OB_________________________________

DUE________________________________ BK_________________________________

Health History: Check if any apply & explain. Use separate paper if necessaryo Diabetes o Seizures &/or Epilepsy o Heart defect/disorder

o Bedwetting o Emotional/Behavioral Disorder o Asthma

o Hay Fever o Bleeding/Clotting Disorder o Frequent Ear Infections

o Other:(specify) _________________________________________

Any Specific Activities to be Restricted __________________________

** ALLERGIES: (Explain reaction as well) Bees or Insect Bites/Stings ___________________________________

Foods (Specify) ___________________________________________

Other (Specify) ___________________________________________

Carries Epipen: ___________________________________________ /Or Inhaler: _____________________________________________

Penicillin: _______________________________________________Immunization History: Actual dates required by NYS Health Department up to age 21, A new copy is required each camp year. Photocopies are preferred.DPT _______ /______/_______/_____ Last Tetanus

Poliomyelitis______/______/_______ MMR_________/

Influenza B _________________ Hepatitis B ____________________

Varicella_______ Chicken Pox _________ Other _________________

The following standard over-the-counter medications are available at the nurse’s office and will be administered as needed at the discretion of an RN, ONLY if approval is indicated by the camper’s health care provider. Without this signature, the camper cannot be given any of these medications under New York State Law.

Drug Name Route Dr.’s Order CommentsCircle preferred formulation(s) Check one

Tylenol Chewable tablet / elixir oYes oNo Pain or Fever > _____ºFIbuprofen Chewable tablet / suspension oYes oNo Pain or Fever > _____ºF

Robitussin Cough & Cold Syrup oYes oNoPepto Bismol Liquid / chewable tablet oYes oNo For diarrhea, upset stomach

Benadryl Chewable tabs or pills oYes oNo Allergic reactionsOther oYes oNo

Health Care Provider’s Signature: __________________________________________

Parent or Guardian ______________________________________ Date __________

(Mr., Mrs., or Reverend)

Notarized: Sworn to me this _______ day of _______________, 20 ______.

Parent’s authorization for those under 18 years of age: In the event I cannot be reached in an emergency I hereby give permission to the physician selected by the camp to hospitalize, secure treatment and order injection, anaesthesia or surgery for my child as named above.* Our local hospitals, for immediate and efficient care in case of emergency, have requested that the Parent’s signature be notarized.

*The registration fee must be sent in with the Registration form in order to be fully Registered. The balance is to be paid on arrival at camp. Money must be in US currency- No Canadian cheques (checks).Camp is filled on a first come, first served basis. It is easierthat you make sure your friend registers at the

same time if you want to bunk together. **PLEASE NOTE: In the event of sickness or illness while at camp, the Parent/Guardian is responsible for all medical expenses incurred under the authori-zation of the Camp Registered Nurse and/or Director. These Claims may be submitted to your insurance provider when eligible for reimbursement.

****In the event of injury or accident while at camp, claims should be submit-ted to your insurance provider. Our camper insurance coverage (accidents or injury only) will be reimbursed you for medical claims which exceed the amount of your personal insurance plan provisions.

METHOD OF PAYMENT Do NOT send cash or checks,

Acceptable Methods of Payment: o Money Order (payable to Circle C Ranch)

Credit Card: o MasterCard o Visa o Discover o Phoned in Payment Total amount being paid $___________

Account Number ________________________________________________ Expiration Date ______________ Security Code _______

Signature ________________________________________________ Print Name ______________________________________

DISCOUNTS!Early Bird: If your registration is postmarked by May 1 you save $20 off your week at camp (Registration fee remains $75). If you’re too late, you can still save $10 by having your registration postmarked by June 1 (Registration fee remains $75).

Extra Week: Pay full price for your first week of camp and every other week you come you get $100 off!

Sibling Discount: When you pay full price for your first child ($305) you get $50 off your second child. If you have a big family, for every sibling after the first two you get $75 dollars off a piece! This discount is for immediate family members only, and cannot be used by cousins, nieces or nephews.

COSTS: Express Week: $75.00 plus $75 non-refundable registration fee. Total $150.00 (U.S. funds) Teen Week / Circle C Has Talent: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds) Regular Weeks Three-Seven: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds)

NOTE: NY State Law requires for horseback riding: 1. Shoes with heels. 2. Helmets (you may bring your own if it is Pony Club Approved)

TWO WAYS TO REGISTER: 1. Mail in the Registration Form and completed Health History with your

$75 registration fee to this address: Living Waters Circle C Ranch 10451 Ashcraft Rd., Delevan, NY 14042-9664 OR

2. Phone in your Registration information to our office and use a credit card (VISA, MASTERCARD, or DISCOVER) for payment of your $75 registration fee. Then, mail in your completed Registration Form and Health History to the above camp address. *We MUST receive this

within two weeks of your phone-in Registration. If we do not, your reservation will be cancelled. (The registration fee is nonrefundable.)

CONTACT INFORMATION: Phone Number (716) 492-3687 or 1-800-231-6866 Fax (716) 492-1361 E-mail: info@circlecranch.org Visit our website: www.circlecranch.org Office Hours: Monday-Friday 9-5 Messages taken by phone on off-hours are not guaranteed.

WHAT TO PACK: Upon receipt of your completed registration information, we will send you “Your Official Circle C Ranch ‘Get Ready for Camp’ checklist” along with your confirmation information.We are not responsible for lost articles

The Public Health Law Requires: 1. The camp be licensed by the NYS Dept. of Health 2. The camp to be inspected twice yearly 3. The inspection reports concerning the camp are filed with the Dept. of Health, 302, Laurens St., Olean, NY.

Rules for acceptance and participation in the program are the same for everyone without regard to race, color, or national origin. Any person who believes he/she has been discriminated against in any USDA-related activity should write immediately to the Secretary of Agriculture, Washington, DC 20250

Please indicate week attending:o Express Week $150/June 21-24

o Teen Week $305/June 26-July 1/Circle C’s Got Talent

o Week Three $305/July 3-8

o Week Four $305/July 10-15

o Week Five $305/July 17-22

o Week Six $305/July 24 – 29

o Week 7 $305/July 31-August 5

Must be checked to be registered. o Special Cookout $7.00

Prescription Route DosageSchedule & Indications

Comments

NOTARY SEAL

Every week of camp includes: Horseback riding, Lasertron, Rock wall climbing, Swimming, 60’ X 250’ giant slip-n-slide, Game room, Storm the Fort, Wild games and so much more!

WWW.C IRCL ECRANCH.ORG

familyCAMPAugust 11-13 A great weekend to have family adventures and make memories that will last a life time!! This one packs out quick, so don’t delay!!

If you want any more information you can check out our website (above) or you can download our app for your smart phone!

L i Fe iS GooD oN the Ranch.

June 27-July 2 / $305 / Ages 12+ Teen week is a wild adventure designed just for our teen campers. This year we will be having Circle C Has Talent: The Ultimate Lipsync Battle! You and your cabin will produce and perform an epic lipsync production as part of our competition. You will also be featured in our camp movie, complete with a premiere!

EXpREsSweek T EENweekJune 21-24 / $150 / Ages 8-18

A half week for all ages that is jam packed with as much fun and adventure as we could cram into it!

2017 CAMPER REGISTRATION & MEDICAL FORM(Please complete all information & type or print clearly)

Child’s Name ____________________________________________________________________________________________

Address ________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip _______________

E-Mail _________________________________________________________________________________________________

Date of Birth ____ /____ /_________ Sex o F o M Age ___ Weight ________ Current Grade Level ________________

I prefer to bunk with ________________________________________________ (bunk mates must be within one year of the same age)

Emergency Contacts

Home Phone Cell Phone Work Phone

FATHER’S NAME

MOTHER’S NAME

GUARDIAN

OTHER CONTACT

MEDICAL FORM Insurance Information: Name of Insurance Company: _________________________________________________________________________________

ID# _______________________________________________ Group # _____________________________________________

Policy# ____________________________________________ Certificate# ___________________________________________

Name Of Camper’s Physician: _____________________________ Phone #: ____________________________________________

Date of last Physical____/____/______

2017 FAMILY WEEKEND (August 12-14) REGISTRATION FORM (please type or print)

Adults: Ages 12 and up - $65.00 per person | Child: Ages 5-11 - $35.00 per person | * 4 years of age and under - FREEThis price includes a snack, 5 meals, 2 nights of lodging, and all the activities.

ADULTSName ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

CHILDREN:Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Address _________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip ________________

Phone:(____) _______________________________________ Cell (____) ___________________________________________

E-Mail __________________________________________________________________________________________________

There is a $50.00 (non-refundable) deposit to be sent in with the registration to reserve your unit. Registration begins at 7:00 PM Friday night in Miss Kate’s Place. (32 units available) and the weekend ends after lunch on Sunday.

Send registration to: Circle C Ranch, 10451 Ashcraft Rd. | We accept VISA, Mastercard, and Discover as forms of payment. Delevan, NY 14042

For Office Use Only

RF_________________________________ PC_________________________________ DIS_________________________________

HF_________________________________ SC_________________________________ OB_________________________________

DUE________________________________ BK_________________________________

Health History: Check if any apply & explain. Use separate paper if necessaryo Diabetes o Seizures &/or Epilepsy o Heart defect/disorder

o Bedwetting o Emotional/Behavioral Disorder o Asthma

o Hay Fever o Bleeding/Clotting Disorder o Frequent Ear Infections

o Other:(specify) _________________________________________

Any Specific Activities to be Restricted __________________________

** ALLERGIES: (Explain reaction as well) Bees or Insect Bites/Stings ___________________________________

Foods (Specify) ___________________________________________

Other (Specify) ___________________________________________

Carries Epipen: ___________________________________________ /Or Inhaler: _____________________________________________

Penicillin: _______________________________________________Immunization History: Actual dates required by NYS Health Department up to age 21, A new copy is required each camp year. Photocopies are preferred.DPT _______ /______/_______/_____ Last Tetanus

Poliomyelitis______/______/_______ MMR_________/

Influenza B _________________ Hepatitis B ____________________

Varicella_______ Chicken Pox _________ Other _________________

The following standard over-the-counter medications are available at the nurse’s office and will be administered as needed at the discretion of an RN, ONLY if approval is indicated by the camper’s health care provider. Without this signature, the camper cannot be given any of these medications under New York State Law.

Drug Name Route Dr.’s Order CommentsCircle preferred formulation(s) Check one

Tylenol Chewable tablet / elixir oYes oNo Pain or Fever > _____ºFIbuprofen Chewable tablet / suspension oYes oNo Pain or Fever > _____ºF

Robitussin Cough & Cold Syrup oYes oNoPepto Bismol Liquid / chewable tablet oYes oNo For diarrhea, upset stomach

Benadryl Chewable tabs or pills oYes oNo Allergic reactionsOther oYes oNo

Health Care Provider’s Signature: __________________________________________

Parent or Guardian ______________________________________ Date __________

(Mr., Mrs., or Reverend)

Notarized: Sworn to me this _______ day of _______________, 20 ______.

Parent’s authorization for those under 18 years of age: In the event I cannot be reached in an emergency I hereby give permission to the physician selected by the camp to hospitalize, secure treatment and order injection, anaesthesia or surgery for my child as named above.* Our local hospitals, for immediate and efficient care in case of emergency, have requested that the Parent’s signature be notarized.

*The registration fee must be sent in with the Registration form in order to be fully Registered. The balance is to be paid on arrival at camp. Money must be in US currency- No Canadian cheques (checks).Camp is filled on a first come, first served basis. It is easierthat you make sure your friend registers at the

same time if you want to bunk together. **PLEASE NOTE: In the event of sickness or illness while at camp, the Parent/Guardian is responsible for all medical expenses incurred under the authori-zation of the Camp Registered Nurse and/or Director. These Claims may be submitted to your insurance provider when eligible for reimbursement.

****In the event of injury or accident while at camp, claims should be submit-ted to your insurance provider. Our camper insurance coverage (accidents or injury only) will be reimbursed you for medical claims which exceed the amount of your personal insurance plan provisions.

METHOD OF PAYMENT Do NOT send cash or checks,

Acceptable Methods of Payment: o Money Order (payable to Circle C Ranch)

Credit Card: o MasterCard o Visa o Discover o Phoned in Payment Total amount being paid $___________

Account Number ________________________________________________ Expiration Date ______________ Security Code _______

Signature ________________________________________________ Print Name ______________________________________

DISCOUNTS!Early Bird: If your registration is postmarked by May 1 you save $20 off your week at camp (Registration fee remains $75). If you’re too late, you can still save $10 by having your registration postmarked by June 1 (Registration fee remains $75).

Extra Week: Pay full price for your first week of camp and every other week you come you get $100 off!

Sibling Discount: When you pay full price for your first child ($305) you get $50 off your second child. If you have a big family, for every sibling after the first two you get $75 dollars off a piece! This discount is for immediate family members only, and cannot be used by cousins, nieces or nephews.

COSTS: Express Week: $75.00 plus $75 non-refundable registration fee. Total $150.00 (U.S. funds) Teen Week / Circle C Has Talent: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds) Regular Weeks Three-Seven: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds)

NOTE: NY State Law requires for horseback riding: 1. Shoes with heels. 2. Helmets (you may bring your own if it is Pony Club Approved)

TWO WAYS TO REGISTER: 1. Mail in the Registration Form and completed Health History with your

$75 registration fee to this address: Living Waters Circle C Ranch 10451 Ashcraft Rd., Delevan, NY 14042-9664 OR

2. Phone in your Registration information to our office and use a credit card (VISA, MASTERCARD, or DISCOVER) for payment of your $75 registration fee. Then, mail in your completed Registration Form and Health History to the above camp address. *We MUST receive this

within two weeks of your phone-in Registration. If we do not, your reservation will be cancelled. (The registration fee is nonrefundable.)

CONTACT INFORMATION: Phone Number (716) 492-3687 or 1-800-231-6866 Fax (716) 492-1361 E-mail: info@circlecranch.org Visit our website: www.circlecranch.org Office Hours: Monday-Friday 9-5 Messages taken by phone on off-hours are not guaranteed.

WHAT TO PACK: Upon receipt of your completed registration information, we will send you “Your Official Circle C Ranch ‘Get Ready for Camp’ checklist” along with your confirmation information.We are not responsible for lost articles

The Public Health Law Requires: 1. The camp be licensed by the NYS Dept. of Health 2. The camp to be inspected twice yearly 3. The inspection reports concerning the camp are filed with the Dept. of Health, 302, Laurens St., Olean, NY.

Rules for acceptance and participation in the program are the same for everyone without regard to race, color, or national origin. Any person who believes he/she has been discriminated against in any USDA-related activity should write immediately to the Secretary of Agriculture, Washington, DC 20250

Please indicate week attending:o Express Week $150/June 21-24

o Teen Week $305/June 26-July 1/Circle C’s Got Talent

o Week Three $305/July 3-8

o Week Four $305/July 10-15

o Week Five $305/July 17-22

o Week Six $305/July 24 – 29

o Week 7 $305/July 31-August 5

Must be checked to be registered. o Special Cookout $7.00

Prescription Route DosageSchedule & Indications

Comments

NOTARY SEAL

Every week of camp includes: Horseback riding, Lasertron, Rock wall climbing, Swimming, 60’ X 250’ giant slip-n-slide, Game room, Storm the Fort, Wild games and so much more!

July 3-Aug. 5 / $305 / Ages 8-18 Fun-filled, wildly adventurous weeks with new games and experiences that are sure to be a blast!

SUmMErweeks

iT s YOur SUMmeR...

mAke it Fe arLeS

s.

WWW.C IRCL ECRANCH.ORG

familyCAMPAugust 11-13 A great weekend to have family adventures and make memories that will last a life time!! This one packs out quick, so don’t delay!!

If you want any more information you can check out our website (above) or you can download our app for your smart phone!

L i Fe iS GooD oN the Ranch.

June 27-July 2 / $305 / Ages 12+ Teen week is a wild adventure designed just for our teen campers. This year we will be having Circle C Has Talent: The Ultimate Lipsync Battle! You and your cabin will produce and perform an epic lipsync production as part of our competition. You will also be featured in our camp movie, complete with a premiere!

EXpREsSweek T EENweekJune 21-24 / $150 / Ages 8-18

A half week for all ages that is jam packed with as much fun and adventure as we could cram into it!

2017 CAMPER REGISTRATION & MEDICAL FORM(Please complete all information & type or print clearly)

Child’s Name ____________________________________________________________________________________________

Address ________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip _______________

E-Mail _________________________________________________________________________________________________

Date of Birth ____ /____ /_________ Sex o F o M Age ___ Weight ________ Current Grade Level ________________

I prefer to bunk with ________________________________________________ (bunk mates must be within one year of the same age)

Emergency Contacts

Home Phone Cell Phone Work Phone

FATHER’S NAME

MOTHER’S NAME

GUARDIAN

OTHER CONTACT

MEDICAL FORM Insurance Information: Name of Insurance Company: _________________________________________________________________________________

ID# _______________________________________________ Group # _____________________________________________

Policy# ____________________________________________ Certificate# ___________________________________________

Name Of Camper’s Physician: _____________________________ Phone #: ____________________________________________

Date of last Physical____/____/______

2017 FAMILY WEEKEND (August 12-14) REGISTRATION FORM (please type or print)

Adults: Ages 12 and up - $65.00 per person | Child: Ages 5-11 - $35.00 per person | * 4 years of age and under - FREEThis price includes a snack, 5 meals, 2 nights of lodging, and all the activities.

ADULTSName ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

CHILDREN:Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Address _________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip ________________

Phone:(____) _______________________________________ Cell (____) ___________________________________________

E-Mail __________________________________________________________________________________________________

There is a $50.00 (non-refundable) deposit to be sent in with the registration to reserve your unit. Registration begins at 7:00 PM Friday night in Miss Kate’s Place. (32 units available) and the weekend ends after lunch on Sunday.

Send registration to: Circle C Ranch, 10451 Ashcraft Rd. | We accept VISA, Mastercard, and Discover as forms of payment. Delevan, NY 14042

For Office Use Only

RF_________________________________ PC_________________________________ DIS_________________________________

HF_________________________________ SC_________________________________ OB_________________________________

DUE________________________________ BK_________________________________

Health History: Check if any apply & explain. Use separate paper if necessaryo Diabetes o Seizures &/or Epilepsy o Heart defect/disorder

o Bedwetting o Emotional/Behavioral Disorder o Asthma

o Hay Fever o Bleeding/Clotting Disorder o Frequent Ear Infections

o Other:(specify) _________________________________________

Any Specific Activities to be Restricted __________________________

** ALLERGIES: (Explain reaction as well) Bees or Insect Bites/Stings ___________________________________

Foods (Specify) ___________________________________________

Other (Specify) ___________________________________________

Carries Epipen: ___________________________________________ /Or Inhaler: _____________________________________________

Penicillin: _______________________________________________Immunization History: Actual dates required by NYS Health Department up to age 21, A new copy is required each camp year. Photocopies are preferred.DPT _______ /______/_______/_____ Last Tetanus

Poliomyelitis______/______/_______ MMR_________/

Influenza B _________________ Hepatitis B ____________________

Varicella_______ Chicken Pox _________ Other _________________

The following standard over-the-counter medications are available at the nurse’s office and will be administered as needed at the discretion of an RN, ONLY if approval is indicated by the camper’s health care provider. Without this signature, the camper cannot be given any of these medications under New York State Law.

Drug Name Route Dr.’s Order CommentsCircle preferred formulation(s) Check one

Tylenol Chewable tablet / elixir oYes oNo Pain or Fever > _____ºFIbuprofen Chewable tablet / suspension oYes oNo Pain or Fever > _____ºF

Robitussin Cough & Cold Syrup oYes oNoPepto Bismol Liquid / chewable tablet oYes oNo For diarrhea, upset stomach

Benadryl Chewable tabs or pills oYes oNo Allergic reactionsOther oYes oNo

Health Care Provider’s Signature: __________________________________________

Parent or Guardian ______________________________________ Date __________

(Mr., Mrs., or Reverend)

Notarized: Sworn to me this _______ day of _______________, 20 ______.

Parent’s authorization for those under 18 years of age: In the event I cannot be reached in an emergency I hereby give permission to the physician selected by the camp to hospitalize, secure treatment and order injection, anaesthesia or surgery for my child as named above.* Our local hospitals, for immediate and efficient care in case of emergency, have requested that the Parent’s signature be notarized.

*The registration fee must be sent in with the Registration form in order to be fully Registered. The balance is to be paid on arrival at camp. Money must be in US currency- No Canadian cheques (checks).Camp is filled on a first come, first served basis. It is easierthat you make sure your friend registers at the

same time if you want to bunk together. **PLEASE NOTE: In the event of sickness or illness while at camp, the Parent/Guardian is responsible for all medical expenses incurred under the authori-zation of the Camp Registered Nurse and/or Director. These Claims may be submitted to your insurance provider when eligible for reimbursement.

****In the event of injury or accident while at camp, claims should be submit-ted to your insurance provider. Our camper insurance coverage (accidents or injury only) will be reimbursed you for medical claims which exceed the amount of your personal insurance plan provisions.

METHOD OF PAYMENT Do NOT send cash or checks,

Acceptable Methods of Payment: o Money Order (payable to Circle C Ranch)

Credit Card: o MasterCard o Visa o Discover o Phoned in Payment Total amount being paid $___________

Account Number ________________________________________________ Expiration Date ______________ Security Code _______

Signature ________________________________________________ Print Name ______________________________________

DISCOUNTS!Early Bird: If your registration is postmarked by May 1 you save $20 off your week at camp (Registration fee remains $75). If you’re too late, you can still save $10 by having your registration postmarked by June 1 (Registration fee remains $75).

Extra Week: Pay full price for your first week of camp and every other week you come you get $100 off!

Sibling Discount: When you pay full price for your first child ($305) you get $50 off your second child. If you have a big family, for every sibling after the first two you get $75 dollars off a piece! This discount is for immediate family members only, and cannot be used by cousins, nieces or nephews.

COSTS: Express Week: $75.00 plus $75 non-refundable registration fee. Total $150.00 (U.S. funds) Teen Week / Circle C Has Talent: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds) Regular Weeks Three-Seven: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds)

NOTE: NY State Law requires for horseback riding: 1. Shoes with heels. 2. Helmets (you may bring your own if it is Pony Club Approved)

TWO WAYS TO REGISTER: 1. Mail in the Registration Form and completed Health History with your

$75 registration fee to this address: Living Waters Circle C Ranch 10451 Ashcraft Rd., Delevan, NY 14042-9664 OR

2. Phone in your Registration information to our office and use a credit card (VISA, MASTERCARD, or DISCOVER) for payment of your $75 registration fee. Then, mail in your completed Registration Form and Health History to the above camp address. *We MUST receive this

within two weeks of your phone-in Registration. If we do not, your reservation will be cancelled. (The registration fee is nonrefundable.)

CONTACT INFORMATION: Phone Number (716) 492-3687 or 1-800-231-6866 Fax (716) 492-1361 E-mail: info@circlecranch.org Visit our website: www.circlecranch.org Office Hours: Monday-Friday 9-5 Messages taken by phone on off-hours are not guaranteed.

WHAT TO PACK: Upon receipt of your completed registration information, we will send you “Your Official Circle C Ranch ‘Get Ready for Camp’ checklist” along with your confirmation information.We are not responsible for lost articles

The Public Health Law Requires: 1. The camp be licensed by the NYS Dept. of Health 2. The camp to be inspected twice yearly 3. The inspection reports concerning the camp are filed with the Dept. of Health, 302, Laurens St., Olean, NY.

Rules for acceptance and participation in the program are the same for everyone without regard to race, color, or national origin. Any person who believes he/she has been discriminated against in any USDA-related activity should write immediately to the Secretary of Agriculture, Washington, DC 20250

Please indicate week attending:o Express Week $150/June 21-24

o Teen Week $305/June 26-July 1/Circle C’s Got Talent

o Week Three $305/July 3-8

o Week Four $305/July 10-15

o Week Five $305/July 17-22

o Week Six $305/July 24 – 29

o Week 7 $305/July 31-August 5

Must be checked to be registered. o Special Cookout $7.00

Prescription Route DosageSchedule & Indications

Comments

NOTARY SEAL

Every week of camp includes: Horseback riding, Lasertron, Rock wall climbing, Swimming, 60’ X 250’ giant slip-n-slide, Game room, Storm the Fort, Wild games and so much more!

WWW.C IRCL ECRANCH.ORG

familyCAMPAugust 11-13 A great weekend to have family adventures and make memories that will last a life time!! This one packs out quick, so don’t delay!!

If you want any more information you can check out our website (above) or you can download our app for your smart phone!

L i Fe iS GooD oN the Ranch.

June 27-July 2 / $305 / Ages 12+ Teen week is a wild adventure designed just for our teen campers. This year we will be having Circle C Has Talent: The Ultimate Lipsync Battle! You and your cabin will produce and perform an epic lipsync production as part of our competition. You will also be featured in our camp movie, complete with a premiere!

EXpREsSweek T EENweekJune 21-24 / $150 / Ages 8-18

A half week for all ages that is jam packed with as much fun and adventure as we could cram into it!

2017 CAMPER REGISTRATION & MEDICAL FORM(Please complete all information & type or print clearly)

Child’s Name ____________________________________________________________________________________________

Address ________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip _______________

E-Mail _________________________________________________________________________________________________

Date of Birth ____ /____ /_________ Sex o F o M Age ___ Weight ________ Current Grade Level ________________

I prefer to bunk with ________________________________________________ (bunk mates must be within one year of the same age)

Emergency Contacts

Home Phone Cell Phone Work Phone

FATHER’S NAME

MOTHER’S NAME

GUARDIAN

OTHER CONTACT

MEDICAL FORM Insurance Information: Name of Insurance Company: _________________________________________________________________________________

ID# _______________________________________________ Group # _____________________________________________

Policy# ____________________________________________ Certificate# ___________________________________________

Name Of Camper’s Physician: _____________________________ Phone #: ____________________________________________

Date of last Physical____/____/______

2017 FAMILY WEEKEND (August 12-14) REGISTRATION FORM (please type or print)

Adults: Ages 12 and up - $65.00 per person | Child: Ages 5-11 - $35.00 per person | * 4 years of age and under - FREEThis price includes a snack, 5 meals, 2 nights of lodging, and all the activities.

ADULTSName ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

CHILDREN:Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Address _________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip ________________

Phone:(____) _______________________________________ Cell (____) ___________________________________________

E-Mail __________________________________________________________________________________________________

There is a $50.00 (non-refundable) deposit to be sent in with the registration to reserve your unit. Registration begins at 7:00 PM Friday night in Miss Kate’s Place. (32 units available) and the weekend ends after lunch on Sunday.

Send registration to: Circle C Ranch, 10451 Ashcraft Rd. | We accept VISA, Mastercard, and Discover as forms of payment. Delevan, NY 14042

For Office Use Only

RF_________________________________ PC_________________________________ DIS_________________________________

HF_________________________________ SC_________________________________ OB_________________________________

DUE________________________________ BK_________________________________

Health History: Check if any apply & explain. Use separate paper if necessaryo Diabetes o Seizures &/or Epilepsy o Heart defect/disorder

o Bedwetting o Emotional/Behavioral Disorder o Asthma

o Hay Fever o Bleeding/Clotting Disorder o Frequent Ear Infections

o Other:(specify) _________________________________________

Any Specific Activities to be Restricted __________________________

** ALLERGIES: (Explain reaction as well) Bees or Insect Bites/Stings ___________________________________

Foods (Specify) ___________________________________________

Other (Specify) ___________________________________________

Carries Epipen: ___________________________________________ /Or Inhaler: _____________________________________________

Penicillin: _______________________________________________Immunization History: Actual dates required by NYS Health Department up to age 21, A new copy is required each camp year. Photocopies are preferred.DPT _______ /______/_______/_____ Last Tetanus

Poliomyelitis______/______/_______ MMR_________/

Influenza B _________________ Hepatitis B ____________________

Varicella_______ Chicken Pox _________ Other _________________

The following standard over-the-counter medications are available at the nurse’s office and will be administered as needed at the discretion of an RN, ONLY if approval is indicated by the camper’s health care provider. Without this signature, the camper cannot be given any of these medications under New York State Law.

Drug Name Route Dr.’s Order CommentsCircle preferred formulation(s) Check one

Tylenol Chewable tablet / elixir oYes oNo Pain or Fever > _____ºFIbuprofen Chewable tablet / suspension oYes oNo Pain or Fever > _____ºF

Robitussin Cough & Cold Syrup oYes oNoPepto Bismol Liquid / chewable tablet oYes oNo For diarrhea, upset stomach

Benadryl Chewable tabs or pills oYes oNo Allergic reactionsOther oYes oNo

Health Care Provider’s Signature: __________________________________________

Parent or Guardian ______________________________________ Date __________

(Mr., Mrs., or Reverend)

Notarized: Sworn to me this _______ day of _______________, 20 ______.

Parent’s authorization for those under 18 years of age: In the event I cannot be reached in an emergency I hereby give permission to the physician selected by the camp to hospitalize, secure treatment and order injection, anaesthesia or surgery for my child as named above.* Our local hospitals, for immediate and efficient care in case of emergency, have requested that the Parent’s signature be notarized.

*The registration fee must be sent in with the Registration form in order to be fully Registered. The balance is to be paid on arrival at camp. Money must be in US currency- No Canadian cheques (checks).Camp is filled on a first come, first served basis. It is easierthat you make sure your friend registers at the

same time if you want to bunk together. **PLEASE NOTE: In the event of sickness or illness while at camp, the Parent/Guardian is responsible for all medical expenses incurred under the authori-zation of the Camp Registered Nurse and/or Director. These Claims may be submitted to your insurance provider when eligible for reimbursement.

****In the event of injury or accident while at camp, claims should be submit-ted to your insurance provider. Our camper insurance coverage (accidents or injury only) will be reimbursed you for medical claims which exceed the amount of your personal insurance plan provisions.

METHOD OF PAYMENT Do NOT send cash or checks,

Acceptable Methods of Payment: o Money Order (payable to Circle C Ranch)

Credit Card: o MasterCard o Visa o Discover o Phoned in Payment Total amount being paid $___________

Account Number ________________________________________________ Expiration Date ______________ Security Code _______

Signature ________________________________________________ Print Name ______________________________________

DISCOUNTS!Early Bird: If your registration is postmarked by May 1 you save $20 off your week at camp (Registration fee remains $75). If you’re too late, you can still save $10 by having your registration postmarked by June 1 (Registration fee remains $75).

Extra Week: Pay full price for your first week of camp and every other week you come you get $100 off!

Sibling Discount: When you pay full price for your first child ($305) you get $50 off your second child. If you have a big family, for every sibling after the first two you get $75 dollars off a piece! This discount is for immediate family members only, and cannot be used by cousins, nieces or nephews.

COSTS: Express Week: $75.00 plus $75 non-refundable registration fee. Total $150.00 (U.S. funds) Teen Week / Circle C Has Talent: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds) Regular Weeks Three-Seven: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds)

NOTE: NY State Law requires for horseback riding: 1. Shoes with heels. 2. Helmets (you may bring your own if it is Pony Club Approved)

TWO WAYS TO REGISTER: 1. Mail in the Registration Form and completed Health History with your

$75 registration fee to this address: Living Waters Circle C Ranch 10451 Ashcraft Rd., Delevan, NY 14042-9664 OR

2. Phone in your Registration information to our office and use a credit card (VISA, MASTERCARD, or DISCOVER) for payment of your $75 registration fee. Then, mail in your completed Registration Form and Health History to the above camp address. *We MUST receive this

within two weeks of your phone-in Registration. If we do not, your reservation will be cancelled. (The registration fee is nonrefundable.)

CONTACT INFORMATION: Phone Number (716) 492-3687 or 1-800-231-6866 Fax (716) 492-1361 E-mail: info@circlecranch.org Visit our website: www.circlecranch.org Office Hours: Monday-Friday 9-5 Messages taken by phone on off-hours are not guaranteed.

WHAT TO PACK: Upon receipt of your completed registration information, we will send you “Your Official Circle C Ranch ‘Get Ready for Camp’ checklist” along with your confirmation information.We are not responsible for lost articles

The Public Health Law Requires: 1. The camp be licensed by the NYS Dept. of Health 2. The camp to be inspected twice yearly 3. The inspection reports concerning the camp are filed with the Dept. of Health, 302, Laurens St., Olean, NY.

Rules for acceptance and participation in the program are the same for everyone without regard to race, color, or national origin. Any person who believes he/she has been discriminated against in any USDA-related activity should write immediately to the Secretary of Agriculture, Washington, DC 20250

Please indicate week attending:o Express Week $150/June 21-24

o Teen Week $305/June 26-July 1/Circle C’s Got Talent

o Week Three $305/July 3-8

o Week Four $305/July 10-15

o Week Five $305/July 17-22

o Week Six $305/July 24 – 29

o Week 7 $305/July 31-August 5

Must be checked to be registered. o Special Cookout $7.00

Prescription Route DosageSchedule & Indications

Comments

NOTARY SEAL

Every week of camp includes: Horseback riding, Lasertron, Rock wall climbing, Swimming, 60’ X 250’ giant slip-n-slide, Game room, Storm the Fort, Wild games and so much more!

WWW.C IRCL ECRANCH.ORG

familyCAMPAugust 11-13 A great weekend to have family adventures and make memories that will last a life time!! This one packs out quick, so don’t delay!!

If you want any more information you can check out our website (above) or you can download our app for your smart phone!

L i Fe iS GooD oN the Ranch.

June 27-July 2 / $305 / Ages 12+ Teen week is a wild adventure designed just for our teen campers. This year we will be having Circle C Has Talent: The Ultimate Lipsync Battle! You and your cabin will produce and perform an epic lipsync production as part of our competition. You will also be featured in our camp movie, complete with a premiere!

EXpREsSweek T EENweekJune 21-24 / $150 / Ages 8-18

A half week for all ages that is jam packed with as much fun and adventure as we could cram into it!

2017 CAMPER REGISTRATION & MEDICAL FORM(Please complete all information & type or print clearly)

Child’s Name ____________________________________________________________________________________________

Address ________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip _______________

E-Mail _________________________________________________________________________________________________

Date of Birth ____ /____ /_________ Sex o F o M Age ___ Weight ________ Current Grade Level ________________

I prefer to bunk with ________________________________________________ (bunk mates must be within one year of the same age)

Emergency Contacts

Home Phone Cell Phone Work Phone

FATHER’S NAME

MOTHER’S NAME

GUARDIAN

OTHER CONTACT

MEDICAL FORM Insurance Information: Name of Insurance Company: _________________________________________________________________________________

ID# _______________________________________________ Group # _____________________________________________

Policy# ____________________________________________ Certificate# ___________________________________________

Name Of Camper’s Physician: _____________________________ Phone #: ____________________________________________

Date of last Physical____/____/______

2017 FAMILY WEEKEND (August 12-14) REGISTRATION FORM (please type or print)

Adults: Ages 12 and up - $65.00 per person | Child: Ages 5-11 - $35.00 per person | * 4 years of age and under - FREEThis price includes a snack, 5 meals, 2 nights of lodging, and all the activities.

ADULTSName ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

CHILDREN:Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Address _________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip ________________

Phone:(____) _______________________________________ Cell (____) ___________________________________________

E-Mail __________________________________________________________________________________________________

There is a $50.00 (non-refundable) deposit to be sent in with the registration to reserve your unit. Registration begins at 7:00 PM Friday night in Miss Kate’s Place. (32 units available) and the weekend ends after lunch on Sunday.

Send registration to: Circle C Ranch, 10451 Ashcraft Rd. | We accept VISA, Mastercard, and Discover as forms of payment. Delevan, NY 14042

For Office Use Only

RF_________________________________ PC_________________________________ DIS_________________________________

HF_________________________________ SC_________________________________ OB_________________________________

DUE________________________________ BK_________________________________

Health History: Check if any apply & explain. Use separate paper if necessaryo Diabetes o Seizures &/or Epilepsy o Heart defect/disorder

o Bedwetting o Emotional/Behavioral Disorder o Asthma

o Hay Fever o Bleeding/Clotting Disorder o Frequent Ear Infections

o Other:(specify) _________________________________________

Any Specific Activities to be Restricted __________________________

** ALLERGIES: (Explain reaction as well) Bees or Insect Bites/Stings ___________________________________

Foods (Specify) ___________________________________________

Other (Specify) ___________________________________________

Carries Epipen: ___________________________________________ /Or Inhaler: _____________________________________________

Penicillin: _______________________________________________Immunization History: Actual dates required by NYS Health Department up to age 21, A new copy is required each camp year. Photocopies are preferred.DPT _______ /______/_______/_____ Last Tetanus

Poliomyelitis______/______/_______ MMR_________/

Influenza B _________________ Hepatitis B ____________________

Varicella_______ Chicken Pox _________ Other _________________

The following standard over-the-counter medications are available at the nurse’s office and will be administered as needed at the discretion of an RN, ONLY if approval is indicated by the camper’s health care provider. Without this signature, the camper cannot be given any of these medications under New York State Law.

Drug Name Route Dr.’s Order CommentsCircle preferred formulation(s) Check one

Tylenol Chewable tablet / elixir oYes oNo Pain or Fever > _____ºFIbuprofen Chewable tablet / suspension oYes oNo Pain or Fever > _____ºF

Robitussin Cough & Cold Syrup oYes oNoPepto Bismol Liquid / chewable tablet oYes oNo For diarrhea, upset stomach

Benadryl Chewable tabs or pills oYes oNo Allergic reactionsOther oYes oNo

Health Care Provider’s Signature: __________________________________________

Parent or Guardian ______________________________________ Date __________

(Mr., Mrs., or Reverend)

Notarized: Sworn to me this _______ day of _______________, 20 ______.

Parent’s authorization for those under 18 years of age: In the event I cannot be reached in an emergency I hereby give permission to the physician selected by the camp to hospitalize, secure treatment and order injection, anaesthesia or surgery for my child as named above.* Our local hospitals, for immediate and efficient care in case of emergency, have requested that the Parent’s signature be notarized.

*The registration fee must be sent in with the Registration form in order to be fully Registered. The balance is to be paid on arrival at camp. Money must be in US currency- No Canadian cheques (checks).Camp is filled on a first come, first served basis. It is easierthat you make sure your friend registers at the

same time if you want to bunk together. **PLEASE NOTE: In the event of sickness or illness while at camp, the Parent/Guardian is responsible for all medical expenses incurred under the authori-zation of the Camp Registered Nurse and/or Director. These Claims may be submitted to your insurance provider when eligible for reimbursement.

****In the event of injury or accident while at camp, claims should be submit-ted to your insurance provider. Our camper insurance coverage (accidents or injury only) will be reimbursed you for medical claims which exceed the amount of your personal insurance plan provisions.

METHOD OF PAYMENT Do NOT send cash or checks,

Acceptable Methods of Payment: o Money Order (payable to Circle C Ranch)

Credit Card: o MasterCard o Visa o Discover o Phoned in Payment Total amount being paid $___________

Account Number ________________________________________________ Expiration Date ______________ Security Code _______

Signature ________________________________________________ Print Name ______________________________________

DISCOUNTS!Early Bird: If your registration is postmarked by May 1 you save $20 off your week at camp (Registration fee remains $75). If you’re too late, you can still save $10 by having your registration postmarked by June 1 (Registration fee remains $75).

Extra Week: Pay full price for your first week of camp and every other week you come you get $100 off!

Sibling Discount: When you pay full price for your first child ($305) you get $50 off your second child. If you have a big family, for every sibling after the first two you get $75 dollars off a piece! This discount is for immediate family members only, and cannot be used by cousins, nieces or nephews.

COSTS: Express Week: $75.00 plus $75 non-refundable registration fee. Total $150.00 (U.S. funds) Teen Week / Circle C Has Talent: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds) Regular Weeks Three-Seven: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds)

NOTE: NY State Law requires for horseback riding: 1. Shoes with heels. 2. Helmets (you may bring your own if it is Pony Club Approved)

TWO WAYS TO REGISTER: 1. Mail in the Registration Form and completed Health History with your

$75 registration fee to this address: Living Waters Circle C Ranch 10451 Ashcraft Rd., Delevan, NY 14042-9664 OR

2. Phone in your Registration information to our office and use a credit card (VISA, MASTERCARD, or DISCOVER) for payment of your $75 registration fee. Then, mail in your completed Registration Form and Health History to the above camp address. *We MUST receive this

within two weeks of your phone-in Registration. If we do not, your reservation will be cancelled. (The registration fee is nonrefundable.)

CONTACT INFORMATION: Phone Number (716) 492-3687 or 1-800-231-6866 Fax (716) 492-1361 E-mail: info@circlecranch.org Visit our website: www.circlecranch.org Office Hours: Monday-Friday 9-5 Messages taken by phone on off-hours are not guaranteed.

WHAT TO PACK: Upon receipt of your completed registration information, we will send you “Your Official Circle C Ranch ‘Get Ready for Camp’ checklist” along with your confirmation information.We are not responsible for lost articles

The Public Health Law Requires: 1. The camp be licensed by the NYS Dept. of Health 2. The camp to be inspected twice yearly 3. The inspection reports concerning the camp are filed with the Dept. of Health, 302, Laurens St., Olean, NY.

Rules for acceptance and participation in the program are the same for everyone without regard to race, color, or national origin. Any person who believes he/she has been discriminated against in any USDA-related activity should write immediately to the Secretary of Agriculture, Washington, DC 20250

Please indicate week attending:o Express Week $150/June 21-24

o Teen Week $305/June 26-July 1/Circle C’s Got Talent

o Week Three $305/July 3-8

o Week Four $305/July 10-15

o Week Five $305/July 17-22

o Week Six $305/July 24 – 29

o Week 7 $305/July 31-August 5

Must be checked to be registered. o Special Cookout $7.00

Prescription Route DosageSchedule & Indications

Comments

NOTARY SEAL

Every week of camp includes: Horseback riding, Lasertron, Rock wall climbing, Swimming, 60’ X 250’ giant slip-n-slide, Game room, Storm the Fort, Wild games and so much more!

WWW.C IRCL ECRANCH.ORG

familyCAMPAugust 11-13 A great weekend to have family adventures and make memories that will last a life time!! This one packs out quick, so don’t delay!!

If you want any more information you can check out our website (above) or you can download our app for your smart phone!

L i Fe iS GooD oN the Ranch.

June 27-July 2 / $305 / Ages 12+ Teen week is a wild adventure designed just for our teen campers. This year we will be having Circle C Has Talent: The Ultimate Lipsync Battle! You and your cabin will produce and perform an epic lipsync production as part of our competition. You will also be featured in our camp movie, complete with a premiere!

EXpREsSweek T EENweekJune 21-24 / $150 / Ages 8-18

A half week for all ages that is jam packed with as much fun and adventure as we could cram into it!

2017 CAMPER REGISTRATION & MEDICAL FORM(Please complete all information & type or print clearly)

Child’s Name ____________________________________________________________________________________________

Address ________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip _______________

E-Mail _________________________________________________________________________________________________

Date of Birth ____ /____ /_________ Sex o F o M Age ___ Weight ________ Current Grade Level ________________

I prefer to bunk with ________________________________________________ (bunk mates must be within one year of the same age)

Emergency Contacts

Home Phone Cell Phone Work Phone

FATHER’S NAME

MOTHER’S NAME

GUARDIAN

OTHER CONTACT

MEDICAL FORM Insurance Information: Name of Insurance Company: _________________________________________________________________________________

ID# _______________________________________________ Group # _____________________________________________

Policy# ____________________________________________ Certificate# ___________________________________________

Name Of Camper’s Physician: _____________________________ Phone #: ____________________________________________

Date of last Physical____/____/______

2017 FAMILY WEEKEND (August 12-14) REGISTRATION FORM (please type or print)

Adults: Ages 12 and up - $65.00 per person | Child: Ages 5-11 - $35.00 per person | * 4 years of age and under - FREEThis price includes a snack, 5 meals, 2 nights of lodging, and all the activities.

ADULTSName ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

CHILDREN:Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Address _________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip ________________

Phone:(____) _______________________________________ Cell (____) ___________________________________________

E-Mail __________________________________________________________________________________________________

There is a $50.00 (non-refundable) deposit to be sent in with the registration to reserve your unit. Registration begins at 7:00 PM Friday night in Miss Kate’s Place. (32 units available) and the weekend ends after lunch on Sunday.

Send registration to: Circle C Ranch, 10451 Ashcraft Rd. | We accept VISA, Mastercard, and Discover as forms of payment. Delevan, NY 14042

For Office Use Only

RF_________________________________ PC_________________________________ DIS_________________________________

HF_________________________________ SC_________________________________ OB_________________________________

DUE________________________________ BK_________________________________

Health History: Check if any apply & explain. Use separate paper if necessaryo Diabetes o Seizures &/or Epilepsy o Heart defect/disorder

o Bedwetting o Emotional/Behavioral Disorder o Asthma

o Hay Fever o Bleeding/Clotting Disorder o Frequent Ear Infections

o Other:(specify) _________________________________________

Any Specific Activities to be Restricted __________________________

** ALLERGIES: (Explain reaction as well) Bees or Insect Bites/Stings ___________________________________

Foods (Specify) ___________________________________________

Other (Specify) ___________________________________________

Carries Epipen: ___________________________________________ /Or Inhaler: _____________________________________________

Penicillin: _______________________________________________Immunization History: Actual dates required by NYS Health Department up to age 21, A new copy is required each camp year. Photocopies are preferred.DPT _______ /______/_______/_____ Last Tetanus

Poliomyelitis______/______/_______ MMR_________/

Influenza B _________________ Hepatitis B ____________________

Varicella_______ Chicken Pox _________ Other _________________

The following standard over-the-counter medications are available at the nurse’s office and will be administered as needed at the discretion of an RN, ONLY if approval is indicated by the camper’s health care provider. Without this signature, the camper cannot be given any of these medications under New York State Law.

Drug Name Route Dr.’s Order CommentsCircle preferred formulation(s) Check one

Tylenol Chewable tablet / elixir oYes oNo Pain or Fever > _____ºFIbuprofen Chewable tablet / suspension oYes oNo Pain or Fever > _____ºF

Robitussin Cough & Cold Syrup oYes oNoPepto Bismol Liquid / chewable tablet oYes oNo For diarrhea, upset stomach

Benadryl Chewable tabs or pills oYes oNo Allergic reactionsOther oYes oNo

Health Care Provider’s Signature: __________________________________________

Parent or Guardian ______________________________________ Date __________

(Mr., Mrs., or Reverend)

Notarized: Sworn to me this _______ day of _______________, 20 ______.

Parent’s authorization for those under 18 years of age: In the event I cannot be reached in an emergency I hereby give permission to the physician selected by the camp to hospitalize, secure treatment and order injection, anaesthesia or surgery for my child as named above.* Our local hospitals, for immediate and efficient care in case of emergency, have requested that the Parent’s signature be notarized.

*The registration fee must be sent in with the Registration form in order to be fully Registered. The balance is to be paid on arrival at camp. Money must be in US currency- No Canadian cheques (checks).Camp is filled on a first come, first served basis. It is easierthat you make sure your friend registers at the

same time if you want to bunk together. **PLEASE NOTE: In the event of sickness or illness while at camp, the Parent/Guardian is responsible for all medical expenses incurred under the authori-zation of the Camp Registered Nurse and/or Director. These Claims may be submitted to your insurance provider when eligible for reimbursement.

****In the event of injury or accident while at camp, claims should be submit-ted to your insurance provider. Our camper insurance coverage (accidents or injury only) will be reimbursed you for medical claims which exceed the amount of your personal insurance plan provisions.

METHOD OF PAYMENT Do NOT send cash or checks,

Acceptable Methods of Payment: o Money Order (payable to Circle C Ranch)

Credit Card: o MasterCard o Visa o Discover o Phoned in Payment Total amount being paid $___________

Account Number ________________________________________________ Expiration Date ______________ Security Code _______

Signature ________________________________________________ Print Name ______________________________________

DISCOUNTS!Early Bird: If your registration is postmarked by May 1 you save $20 off your week at camp (Registration fee remains $75). If you’re too late, you can still save $10 by having your registration postmarked by June 1 (Registration fee remains $75).

Extra Week: Pay full price for your first week of camp and every other week you come you get $100 off!

Sibling Discount: When you pay full price for your first child ($305) you get $50 off your second child. If you have a big family, for every sibling after the first two you get $75 dollars off a piece! This discount is for immediate family members only, and cannot be used by cousins, nieces or nephews.

COSTS: Express Week: $75.00 plus $75 non-refundable registration fee. Total $150.00 (U.S. funds) Teen Week / Circle C Has Talent: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds) Regular Weeks Three-Seven: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds)

NOTE: NY State Law requires for horseback riding: 1. Shoes with heels. 2. Helmets (you may bring your own if it is Pony Club Approved)

TWO WAYS TO REGISTER: 1. Mail in the Registration Form and completed Health History with your

$75 registration fee to this address: Living Waters Circle C Ranch 10451 Ashcraft Rd., Delevan, NY 14042-9664 OR

2. Phone in your Registration information to our office and use a credit card (VISA, MASTERCARD, or DISCOVER) for payment of your $75 registration fee. Then, mail in your completed Registration Form and Health History to the above camp address. *We MUST receive this

within two weeks of your phone-in Registration. If we do not, your reservation will be cancelled. (The registration fee is nonrefundable.)

CONTACT INFORMATION: Phone Number (716) 492-3687 or 1-800-231-6866 Fax (716) 492-1361 E-mail: info@circlecranch.org Visit our website: www.circlecranch.org Office Hours: Monday-Friday 9-5 Messages taken by phone on off-hours are not guaranteed.

WHAT TO PACK: Upon receipt of your completed registration information, we will send you “Your Official Circle C Ranch ‘Get Ready for Camp’ checklist” along with your confirmation information.We are not responsible for lost articles

The Public Health Law Requires: 1. The camp be licensed by the NYS Dept. of Health 2. The camp to be inspected twice yearly 3. The inspection reports concerning the camp are filed with the Dept. of Health, 302, Laurens St., Olean, NY.

Rules for acceptance and participation in the program are the same for everyone without regard to race, color, or national origin. Any person who believes he/she has been discriminated against in any USDA-related activity should write immediately to the Secretary of Agriculture, Washington, DC 20250

Please indicate week attending:o Express Week $150/June 21-24

o Teen Week $305/June 26-July 1/Circle C’s Got Talent

o Week Three $305/July 3-8

o Week Four $305/July 10-15

o Week Five $305/July 17-22

o Week Six $305/July 24 – 29

o Week 7 $305/July 31-August 5

Must be checked to be registered. o Special Cookout $7.00

Prescription Route DosageSchedule & Indications

Comments

NOTARY SEAL

Every week of camp includes: Horseback riding, Lasertron, Rock wall climbing, Swimming, 60’ X 250’ giant slip-n-slide, Game room, Storm the Fort, Wild games and so much more!

WWW.C IRCL ECRANCH.ORG

familyCAMPAugust 11-13 A great weekend to have family adventures and make memories that will last a life time!! This one packs out quick, so don’t delay!!

If you want any more information you can check out our website (above) or you can download our app for your smart phone!

L i Fe iS GooD oN the Ranch.

June 27-July 2 / $305 / Ages 12+ Teen week is a wild adventure designed just for our teen campers. This year we will be having Circle C Has Talent: The Ultimate Lipsync Battle! You and your cabin will produce and perform an epic lipsync production as part of our competition. You will also be featured in our camp movie, complete with a premiere!

EXpREsSweek T EENweekJune 21-24 / $150 / Ages 8-18

A half week for all ages that is jam packed with as much fun and adventure as we could cram into it!

2017 CAMPER REGISTRATION & MEDICAL FORM(Please complete all information & type or print clearly)

Child’s Name ____________________________________________________________________________________________

Address ________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip _______________

E-Mail _________________________________________________________________________________________________

Date of Birth ____ /____ /_________ Sex o F o M Age ___ Weight ________ Current Grade Level ________________

I prefer to bunk with ________________________________________________ (bunk mates must be within one year of the same age)

Emergency Contacts

Home Phone Cell Phone Work Phone

FATHER’S NAME

MOTHER’S NAME

GUARDIAN

OTHER CONTACT

MEDICAL FORM Insurance Information: Name of Insurance Company: _________________________________________________________________________________

ID# _______________________________________________ Group # _____________________________________________

Policy# ____________________________________________ Certificate# ___________________________________________

Name Of Camper’s Physician: _____________________________ Phone #: ____________________________________________

Date of last Physical____/____/______

2017 FAMILY WEEKEND (August 12-14) REGISTRATION FORM (please type or print)

Adults: Ages 12 and up - $65.00 per person | Child: Ages 5-11 - $35.00 per person | * 4 years of age and under - FREEThis price includes a snack, 5 meals, 2 nights of lodging, and all the activities.

ADULTSName ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

CHILDREN:Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Address _________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip ________________

Phone:(____) _______________________________________ Cell (____) ___________________________________________

E-Mail __________________________________________________________________________________________________

There is a $50.00 (non-refundable) deposit to be sent in with the registration to reserve your unit. Registration begins at 7:00 PM Friday night in Miss Kate’s Place. (32 units available) and the weekend ends after lunch on Sunday.

Send registration to: Circle C Ranch, 10451 Ashcraft Rd. | We accept VISA, Mastercard, and Discover as forms of payment. Delevan, NY 14042

For Office Use Only

RF_________________________________ PC_________________________________ DIS_________________________________

HF_________________________________ SC_________________________________ OB_________________________________

DUE________________________________ BK_________________________________

Health History: Check if any apply & explain. Use separate paper if necessaryo Diabetes o Seizures &/or Epilepsy o Heart defect/disorder

o Bedwetting o Emotional/Behavioral Disorder o Asthma

o Hay Fever o Bleeding/Clotting Disorder o Frequent Ear Infections

o Other:(specify) _________________________________________

Any Specific Activities to be Restricted __________________________

** ALLERGIES: (Explain reaction as well) Bees or Insect Bites/Stings ___________________________________

Foods (Specify) ___________________________________________

Other (Specify) ___________________________________________

Carries Epipen: ___________________________________________ /Or Inhaler: _____________________________________________

Penicillin: _______________________________________________Immunization History: Actual dates required by NYS Health Department up to age 21, A new copy is required each camp year. Photocopies are preferred.DPT _______ /______/_______/_____ Last Tetanus

Poliomyelitis______/______/_______ MMR_________/

Influenza B _________________ Hepatitis B ____________________

Varicella_______ Chicken Pox _________ Other _________________

The following standard over-the-counter medications are available at the nurse’s office and will be administered as needed at the discretion of an RN, ONLY if approval is indicated by the camper’s health care provider. Without this signature, the camper cannot be given any of these medications under New York State Law.

Drug Name Route Dr.’s Order CommentsCircle preferred formulation(s) Check one

Tylenol Chewable tablet / elixir oYes oNo Pain or Fever > _____ºFIbuprofen Chewable tablet / suspension oYes oNo Pain or Fever > _____ºF

Robitussin Cough & Cold Syrup oYes oNoPepto Bismol Liquid / chewable tablet oYes oNo For diarrhea, upset stomach

Benadryl Chewable tabs or pills oYes oNo Allergic reactionsOther oYes oNo

Health Care Provider’s Signature: __________________________________________

Parent or Guardian ______________________________________ Date __________

(Mr., Mrs., or Reverend)

Notarized: Sworn to me this _______ day of _______________, 20 ______.

Parent’s authorization for those under 18 years of age: In the event I cannot be reached in an emergency I hereby give permission to the physician selected by the camp to hospitalize, secure treatment and order injection, anaesthesia or surgery for my child as named above.* Our local hospitals, for immediate and efficient care in case of emergency, have requested that the Parent’s signature be notarized.

*The registration fee must be sent in with the Registration form in order to be fully Registered. The balance is to be paid on arrival at camp. Money must be in US currency- No Canadian cheques (checks).Camp is filled on a first come, first served basis. It is easierthat you make sure your friend registers at the

same time if you want to bunk together. **PLEASE NOTE: In the event of sickness or illness while at camp, the Parent/Guardian is responsible for all medical expenses incurred under the authori-zation of the Camp Registered Nurse and/or Director. These Claims may be submitted to your insurance provider when eligible for reimbursement.

****In the event of injury or accident while at camp, claims should be submit-ted to your insurance provider. Our camper insurance coverage (accidents or injury only) will be reimbursed you for medical claims which exceed the amount of your personal insurance plan provisions.

METHOD OF PAYMENT Do NOT send cash or checks,

Acceptable Methods of Payment: o Money Order (payable to Circle C Ranch)

Credit Card: o MasterCard o Visa o Discover o Phoned in Payment Total amount being paid $___________

Account Number ________________________________________________ Expiration Date ______________ Security Code _______

Signature ________________________________________________ Print Name ______________________________________

DISCOUNTS!Early Bird: If your registration is postmarked by May 1 you save $20 off your week at camp (Registration fee remains $75). If you’re too late, you can still save $10 by having your registration postmarked by June 1 (Registration fee remains $75).

Extra Week: Pay full price for your first week of camp and every other week you come you get $100 off!

Sibling Discount: When you pay full price for your first child ($305) you get $50 off your second child. If you have a big family, for every sibling after the first two you get $75 dollars off a piece! This discount is for immediate family members only, and cannot be used by cousins, nieces or nephews.

COSTS: Express Week: $75.00 plus $75 non-refundable registration fee. Total $150.00 (U.S. funds) Teen Week / Circle C Has Talent: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds) Regular Weeks Three-Seven: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds)

NOTE: NY State Law requires for horseback riding: 1. Shoes with heels. 2. Helmets (you may bring your own if it is Pony Club Approved)

TWO WAYS TO REGISTER: 1. Mail in the Registration Form and completed Health History with your

$75 registration fee to this address: Living Waters Circle C Ranch 10451 Ashcraft Rd., Delevan, NY 14042-9664 OR

2. Phone in your Registration information to our office and use a credit card (VISA, MASTERCARD, or DISCOVER) for payment of your $75 registration fee. Then, mail in your completed Registration Form and Health History to the above camp address. *We MUST receive this

within two weeks of your phone-in Registration. If we do not, your reservation will be cancelled. (The registration fee is nonrefundable.)

CONTACT INFORMATION: Phone Number (716) 492-3687 or 1-800-231-6866 Fax (716) 492-1361 E-mail: info@circlecranch.org Visit our website: www.circlecranch.org Office Hours: Monday-Friday 9-5 Messages taken by phone on off-hours are not guaranteed.

WHAT TO PACK: Upon receipt of your completed registration information, we will send you “Your Official Circle C Ranch ‘Get Ready for Camp’ checklist” along with your confirmation information.We are not responsible for lost articles

The Public Health Law Requires: 1. The camp be licensed by the NYS Dept. of Health 2. The camp to be inspected twice yearly 3. The inspection reports concerning the camp are filed with the Dept. of Health, 302, Laurens St., Olean, NY.

Rules for acceptance and participation in the program are the same for everyone without regard to race, color, or national origin. Any person who believes he/she has been discriminated against in any USDA-related activity should write immediately to the Secretary of Agriculture, Washington, DC 20250

Please indicate week attending:o Express Week $150/June 21-24

o Teen Week $305/June 26-July 1/Circle C’s Got Talent

o Week Three $305/July 3-8

o Week Four $305/July 10-15

o Week Five $305/July 17-22

o Week Six $305/July 24 – 29

o Week 7 $305/July 31-August 5

Must be checked to be registered. o Special Cookout $7.00

Prescription Route DosageSchedule & Indications

Comments

NOTARY SEAL

Every week of camp includes: Horseback riding, Lasertron, Rock wall climbing, Swimming, 60’ X 250’ giant slip-n-slide, Game room, Storm the Fort, Wild games and so much more!

WWW.C IRCL ECRANCH.ORG

familyCAMPAugust 11-13 A great weekend to have family adventures and make memories that will last a life time!! This one packs out quick, so don’t delay!!

If you want any more information you can check out our website (above) or you can download our app for your smart phone!

L i Fe iS GooD oN the Ranch.

June 27-July 2 / $305 / Ages 12+ Teen week is a wild adventure designed just for our teen campers. This year we will be having Circle C Has Talent: The Ultimate Lipsync Battle! You and your cabin will produce and perform an epic lipsync production as part of our competition. You will also be featured in our camp movie, complete with a premiere!

EXpREsSweek T EENweekJune 21-24 / $150 / Ages 8-18

A half week for all ages that is jam packed with as much fun and adventure as we could cram into it!

2017 CAMPER REGISTRATION & MEDICAL FORM(Please complete all information & type or print clearly)

Child’s Name ____________________________________________________________________________________________

Address ________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip _______________

E-Mail _________________________________________________________________________________________________

Date of Birth ____ /____ /_________ Sex o F o M Age ___ Weight ________ Current Grade Level ________________

I prefer to bunk with ________________________________________________ (bunk mates must be within one year of the same age)

Emergency Contacts

Home Phone Cell Phone Work Phone

FATHER’S NAME

MOTHER’S NAME

GUARDIAN

OTHER CONTACT

MEDICAL FORM Insurance Information: Name of Insurance Company: _________________________________________________________________________________

ID# _______________________________________________ Group # _____________________________________________

Policy# ____________________________________________ Certificate# ___________________________________________

Name Of Camper’s Physician: _____________________________ Phone #: ____________________________________________

Date of last Physical____/____/______

2017 FAMILY WEEKEND (August 12-14) REGISTRATION FORM (please type or print)

Adults: Ages 12 and up - $65.00 per person | Child: Ages 5-11 - $35.00 per person | * 4 years of age and under - FREEThis price includes a snack, 5 meals, 2 nights of lodging, and all the activities.

ADULTSName ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

CHILDREN:Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Address _________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip ________________

Phone:(____) _______________________________________ Cell (____) ___________________________________________

E-Mail __________________________________________________________________________________________________

There is a $50.00 (non-refundable) deposit to be sent in with the registration to reserve your unit. Registration begins at 7:00 PM Friday night in Miss Kate’s Place. (32 units available) and the weekend ends after lunch on Sunday.

Send registration to: Circle C Ranch, 10451 Ashcraft Rd. | We accept VISA, Mastercard, and Discover as forms of payment. Delevan, NY 14042

For Office Use Only

RF_________________________________ PC_________________________________ DIS_________________________________

HF_________________________________ SC_________________________________ OB_________________________________

DUE________________________________ BK_________________________________

Health History: Check if any apply & explain. Use separate paper if necessaryo Diabetes o Seizures &/or Epilepsy o Heart defect/disorder

o Bedwetting o Emotional/Behavioral Disorder o Asthma

o Hay Fever o Bleeding/Clotting Disorder o Frequent Ear Infections

o Other:(specify) _________________________________________

Any Specific Activities to be Restricted __________________________

** ALLERGIES: (Explain reaction as well) Bees or Insect Bites/Stings ___________________________________

Foods (Specify) ___________________________________________

Other (Specify) ___________________________________________

Carries Epipen: ___________________________________________ /Or Inhaler: _____________________________________________

Penicillin: _______________________________________________Immunization History: Actual dates required by NYS Health Department up to age 21, A new copy is required each camp year. Photocopies are preferred.DPT _______ /______/_______/_____ Last Tetanus

Poliomyelitis______/______/_______ MMR_________/

Influenza B _________________ Hepatitis B ____________________

Varicella_______ Chicken Pox _________ Other _________________

The following standard over-the-counter medications are available at the nurse’s office and will be administered as needed at the discretion of an RN, ONLY if approval is indicated by the camper’s health care provider. Without this signature, the camper cannot be given any of these medications under New York State Law.

Drug Name Route Dr.’s Order CommentsCircle preferred formulation(s) Check one

Tylenol Chewable tablet / elixir oYes oNo Pain or Fever > _____ºFIbuprofen Chewable tablet / suspension oYes oNo Pain or Fever > _____ºF

Robitussin Cough & Cold Syrup oYes oNoPepto Bismol Liquid / chewable tablet oYes oNo For diarrhea, upset stomach

Benadryl Chewable tabs or pills oYes oNo Allergic reactionsOther oYes oNo

Health Care Provider’s Signature: __________________________________________

Parent or Guardian ______________________________________ Date __________

(Mr., Mrs., or Reverend)

Notarized: Sworn to me this _______ day of _______________, 20 ______.

Parent’s authorization for those under 18 years of age: In the event I cannot be reached in an emergency I hereby give permission to the physician selected by the camp to hospitalize, secure treatment and order injection, anaesthesia or surgery for my child as named above.* Our local hospitals, for immediate and efficient care in case of emergency, have requested that the Parent’s signature be notarized.

*The registration fee must be sent in with the Registration form in order to be fully Registered. The balance is to be paid on arrival at camp. Money must be in US currency- No Canadian cheques (checks).Camp is filled on a first come, first served basis. It is easierthat you make sure your friend registers at the

same time if you want to bunk together. **PLEASE NOTE: In the event of sickness or illness while at camp, the Parent/Guardian is responsible for all medical expenses incurred under the authori-zation of the Camp Registered Nurse and/or Director. These Claims may be submitted to your insurance provider when eligible for reimbursement.

****In the event of injury or accident while at camp, claims should be submit-ted to your insurance provider. Our camper insurance coverage (accidents or injury only) will be reimbursed you for medical claims which exceed the amount of your personal insurance plan provisions.

METHOD OF PAYMENT Do NOT send cash or checks,

Acceptable Methods of Payment: o Money Order (payable to Circle C Ranch)

Credit Card: o MasterCard o Visa o Discover o Phoned in Payment Total amount being paid $___________

Account Number ________________________________________________ Expiration Date ______________ Security Code _______

Signature ________________________________________________ Print Name ______________________________________

DISCOUNTS!Early Bird: If your registration is postmarked by May 1 you save $20 off your week at camp (Registration fee remains $75). If you’re too late, you can still save $10 by having your registration postmarked by June 1 (Registration fee remains $75).

Extra Week: Pay full price for your first week of camp and every other week you come you get $100 off!

Sibling Discount: When you pay full price for your first child ($305) you get $50 off your second child. If you have a big family, for every sibling after the first two you get $75 dollars off a piece! This discount is for immediate family members only, and cannot be used by cousins, nieces or nephews.

COSTS: Express Week: $75.00 plus $75 non-refundable registration fee. Total $150.00 (U.S. funds) Teen Week / Circle C Has Talent: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds) Regular Weeks Three-Seven: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds)

NOTE: NY State Law requires for horseback riding: 1. Shoes with heels. 2. Helmets (you may bring your own if it is Pony Club Approved)

TWO WAYS TO REGISTER: 1. Mail in the Registration Form and completed Health History with your

$75 registration fee to this address: Living Waters Circle C Ranch 10451 Ashcraft Rd., Delevan, NY 14042-9664 OR

2. Phone in your Registration information to our office and use a credit card (VISA, MASTERCARD, or DISCOVER) for payment of your $75 registration fee. Then, mail in your completed Registration Form and Health History to the above camp address. *We MUST receive this

within two weeks of your phone-in Registration. If we do not, your reservation will be cancelled. (The registration fee is nonrefundable.)

CONTACT INFORMATION: Phone Number (716) 492-3687 or 1-800-231-6866 Fax (716) 492-1361 E-mail: info@circlecranch.org Visit our website: www.circlecranch.org Office Hours: Monday-Friday 9-5 Messages taken by phone on off-hours are not guaranteed.

WHAT TO PACK: Upon receipt of your completed registration information, we will send you “Your Official Circle C Ranch ‘Get Ready for Camp’ checklist” along with your confirmation information.We are not responsible for lost articles

The Public Health Law Requires: 1. The camp be licensed by the NYS Dept. of Health 2. The camp to be inspected twice yearly 3. The inspection reports concerning the camp are filed with the Dept. of Health, 302, Laurens St., Olean, NY.

Rules for acceptance and participation in the program are the same for everyone without regard to race, color, or national origin. Any person who believes he/she has been discriminated against in any USDA-related activity should write immediately to the Secretary of Agriculture, Washington, DC 20250

Please indicate week attending:o Express Week $150/June 21-24

o Teen Week $305/June 26-July 1/Circle C’s Got Talent

o Week Three $305/July 3-8

o Week Four $305/July 10-15

o Week Five $305/July 17-22

o Week Six $305/July 24 – 29

o Week 7 $305/July 31-August 5

Must be checked to be registered. o Special Cookout $7.00

Prescription Route DosageSchedule & Indications

Comments

NOTARY SEAL

Every week of camp includes: Horseback riding, Lasertron, Rock wall climbing, Swimming, 60’ X 250’ giant slip-n-slide, Game room, Storm the Fort, Wild games and so much more!

WWW.C IRCL ECRANCH.ORG

familyCAMPAugust 11-13 A great weekend to have family adventures and make memories that will last a life time!! This one packs out quick, so don’t delay!!

If you want any more information you can check out our website (above) or you can download our app for your smart phone!

L i Fe iS GooD oN the Ranch.

June 27-July 2 / $305 / Ages 12+ Teen week is a wild adventure designed just for our teen campers. This year we will be having Circle C Has Talent: The Ultimate Lipsync Battle! You and your cabin will produce and perform an epic lipsync production as part of our competition. You will also be featured in our camp movie, complete with a premiere!

EXpREsSweek T EENweekJune 21-24 / $150 / Ages 8-18

A half week for all ages that is jam packed with as much fun and adventure as we could cram into it!

2017 CAMPER REGISTRATION & MEDICAL FORM(Please complete all information & type or print clearly)

Child’s Name ____________________________________________________________________________________________

Address ________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip _______________

E-Mail _________________________________________________________________________________________________

Date of Birth ____ /____ /_________ Sex o F o M Age ___ Weight ________ Current Grade Level ________________

I prefer to bunk with ________________________________________________ (bunk mates must be within one year of the same age)

Emergency Contacts

Home Phone Cell Phone Work Phone

FATHER’S NAME

MOTHER’S NAME

GUARDIAN

OTHER CONTACT

MEDICAL FORM Insurance Information: Name of Insurance Company: _________________________________________________________________________________

ID# _______________________________________________ Group # _____________________________________________

Policy# ____________________________________________ Certificate# ___________________________________________

Name Of Camper’s Physician: _____________________________ Phone #: ____________________________________________

Date of last Physical____/____/______

2017 FAMILY WEEKEND (August 12-14) REGISTRATION FORM (please type or print)

Adults: Ages 12 and up - $65.00 per person | Child: Ages 5-11 - $35.00 per person | * 4 years of age and under - FREEThis price includes a snack, 5 meals, 2 nights of lodging, and all the activities.

ADULTSName ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

CHILDREN:Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Address _________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip ________________

Phone:(____) _______________________________________ Cell (____) ___________________________________________

E-Mail __________________________________________________________________________________________________

There is a $50.00 (non-refundable) deposit to be sent in with the registration to reserve your unit. Registration begins at 7:00 PM Friday night in Miss Kate’s Place. (32 units available) and the weekend ends after lunch on Sunday.

Send registration to: Circle C Ranch, 10451 Ashcraft Rd. | We accept VISA, Mastercard, and Discover as forms of payment. Delevan, NY 14042

For Office Use Only

RF_________________________________ PC_________________________________ DIS_________________________________

HF_________________________________ SC_________________________________ OB_________________________________

DUE________________________________ BK_________________________________

Health History: Check if any apply & explain. Use separate paper if necessaryo Diabetes o Seizures &/or Epilepsy o Heart defect/disorder

o Bedwetting o Emotional/Behavioral Disorder o Asthma

o Hay Fever o Bleeding/Clotting Disorder o Frequent Ear Infections

o Other:(specify) _________________________________________

Any Specific Activities to be Restricted __________________________

** ALLERGIES: (Explain reaction as well) Bees or Insect Bites/Stings ___________________________________

Foods (Specify) ___________________________________________

Other (Specify) ___________________________________________

Carries Epipen: ___________________________________________ /Or Inhaler: _____________________________________________

Penicillin: _______________________________________________Immunization History: Actual dates required by NYS Health Department up to age 21, A new copy is required each camp year. Photocopies are preferred.DPT _______ /______/_______/_____ Last Tetanus

Poliomyelitis______/______/_______ MMR_________/

Influenza B _________________ Hepatitis B ____________________

Varicella_______ Chicken Pox _________ Other _________________

The following standard over-the-counter medications are available at the nurse’s office and will be administered as needed at the discretion of an RN, ONLY if approval is indicated by the camper’s health care provider. Without this signature, the camper cannot be given any of these medications under New York State Law.

Drug Name Route Dr.’s Order CommentsCircle preferred formulation(s) Check one

Tylenol Chewable tablet / elixir oYes oNo Pain or Fever > _____ºFIbuprofen Chewable tablet / suspension oYes oNo Pain or Fever > _____ºF

Robitussin Cough & Cold Syrup oYes oNoPepto Bismol Liquid / chewable tablet oYes oNo For diarrhea, upset stomach

Benadryl Chewable tabs or pills oYes oNo Allergic reactionsOther oYes oNo

Health Care Provider’s Signature: __________________________________________

Parent or Guardian ______________________________________ Date __________

(Mr., Mrs., or Reverend)

Notarized: Sworn to me this _______ day of _______________, 20 ______.

Parent’s authorization for those under 18 years of age: In the event I cannot be reached in an emergency I hereby give permission to the physician selected by the camp to hospitalize, secure treatment and order injection, anaesthesia or surgery for my child as named above.* Our local hospitals, for immediate and efficient care in case of emergency, have requested that the Parent’s signature be notarized.

*The registration fee must be sent in with the Registration form in order to be fully Registered. The balance is to be paid on arrival at camp. Money must be in US currency- No Canadian cheques (checks).Camp is filled on a first come, first served basis. It is easierthat you make sure your friend registers at the

same time if you want to bunk together. **PLEASE NOTE: In the event of sickness or illness while at camp, the Parent/Guardian is responsible for all medical expenses incurred under the authori-zation of the Camp Registered Nurse and/or Director. These Claims may be submitted to your insurance provider when eligible for reimbursement.

****In the event of injury or accident while at camp, claims should be submit-ted to your insurance provider. Our camper insurance coverage (accidents or injury only) will be reimbursed you for medical claims which exceed the amount of your personal insurance plan provisions.

METHOD OF PAYMENT Do NOT send cash or checks,

Acceptable Methods of Payment: o Money Order (payable to Circle C Ranch)

Credit Card: o MasterCard o Visa o Discover o Phoned in Payment Total amount being paid $___________

Account Number ________________________________________________ Expiration Date ______________ Security Code _______

Signature ________________________________________________ Print Name ______________________________________

DISCOUNTS!Early Bird: If your registration is postmarked by May 1 you save $20 off your week at camp (Registration fee remains $75). If you’re too late, you can still save $10 by having your registration postmarked by June 1 (Registration fee remains $75).

Extra Week: Pay full price for your first week of camp and every other week you come you get $100 off!

Sibling Discount: When you pay full price for your first child ($305) you get $50 off your second child. If you have a big family, for every sibling after the first two you get $75 dollars off a piece! This discount is for immediate family members only, and cannot be used by cousins, nieces or nephews.

COSTS: Express Week: $75.00 plus $75 non-refundable registration fee. Total $150.00 (U.S. funds) Teen Week / Circle C Has Talent: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds) Regular Weeks Three-Seven: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds)

NOTE: NY State Law requires for horseback riding: 1. Shoes with heels. 2. Helmets (you may bring your own if it is Pony Club Approved)

TWO WAYS TO REGISTER: 1. Mail in the Registration Form and completed Health History with your

$75 registration fee to this address: Living Waters Circle C Ranch 10451 Ashcraft Rd., Delevan, NY 14042-9664 OR

2. Phone in your Registration information to our office and use a credit card (VISA, MASTERCARD, or DISCOVER) for payment of your $75 registration fee. Then, mail in your completed Registration Form and Health History to the above camp address. *We MUST receive this

within two weeks of your phone-in Registration. If we do not, your reservation will be cancelled. (The registration fee is nonrefundable.)

CONTACT INFORMATION: Phone Number (716) 492-3687 or 1-800-231-6866 Fax (716) 492-1361 E-mail: info@circlecranch.org Visit our website: www.circlecranch.org Office Hours: Monday-Friday 9-5 Messages taken by phone on off-hours are not guaranteed.

WHAT TO PACK: Upon receipt of your completed registration information, we will send you “Your Official Circle C Ranch ‘Get Ready for Camp’ checklist” along with your confirmation information.We are not responsible for lost articles

The Public Health Law Requires: 1. The camp be licensed by the NYS Dept. of Health 2. The camp to be inspected twice yearly 3. The inspection reports concerning the camp are filed with the Dept. of Health, 302, Laurens St., Olean, NY.

Rules for acceptance and participation in the program are the same for everyone without regard to race, color, or national origin. Any person who believes he/she has been discriminated against in any USDA-related activity should write immediately to the Secretary of Agriculture, Washington, DC 20250

Please indicate week attending:o Express Week $150/June 21-24

o Teen Week $305/June 26-July 1/Circle C’s Got Talent

o Week Three $305/July 3-8

o Week Four $305/July 10-15

o Week Five $305/July 17-22

o Week Six $305/July 24 – 29

o Week 7 $305/July 31-August 5

Must be checked to be registered. o Special Cookout $7.00

Prescription Route DosageSchedule & Indications

Comments

NOTARY SEAL

Every week of camp includes: Horseback riding, Lasertron, Rock wall climbing, Swimming, 60’ X 250’ giant slip-n-slide, Game room, Storm the Fort, Wild games and so much more!

WWW.C IRCL ECRANCH.ORG

familyCAMPAugust 11-13 A great weekend to have family adventures and make memories that will last a life time!! This one packs out quick, so don’t delay!!

If you want any more information you can check out our website (above) or you can download our app for your smart phone!

L i Fe iS GooD oN the Ranch.

June 27-July 2 / $305 / Ages 12+ Teen week is a wild adventure designed just for our teen campers. This year we will be having Circle C Has Talent: The Ultimate Lipsync Battle! You and your cabin will produce and perform an epic lipsync production as part of our competition. You will also be featured in our camp movie, complete with a premiere!

EXpREsSweek T EENweekJune 21-24 / $150 / Ages 8-18

A half week for all ages that is jam packed with as much fun and adventure as we could cram into it!

2017 CAMPER REGISTRATION & MEDICAL FORM(Please complete all information & type or print clearly)

Child’s Name ____________________________________________________________________________________________

Address ________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip _______________

E-Mail _________________________________________________________________________________________________

Date of Birth ____ /____ /_________ Sex o F o M Age ___ Weight ________ Current Grade Level ________________

I prefer to bunk with ________________________________________________ (bunk mates must be within one year of the same age)

Emergency Contacts

Home Phone Cell Phone Work Phone

FATHER’S NAME

MOTHER’S NAME

GUARDIAN

OTHER CONTACT

MEDICAL FORM Insurance Information: Name of Insurance Company: _________________________________________________________________________________

ID# _______________________________________________ Group # _____________________________________________

Policy# ____________________________________________ Certificate# ___________________________________________

Name Of Camper’s Physician: _____________________________ Phone #: ____________________________________________

Date of last Physical____/____/______

2017 FAMILY WEEKEND (August 12-14) REGISTRATION FORM (please type or print)

Adults: Ages 12 and up - $65.00 per person | Child: Ages 5-11 - $35.00 per person | * 4 years of age and under - FREEThis price includes a snack, 5 meals, 2 nights of lodging, and all the activities.

ADULTSName ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

CHILDREN:Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Address _________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip ________________

Phone:(____) _______________________________________ Cell (____) ___________________________________________

E-Mail __________________________________________________________________________________________________

There is a $50.00 (non-refundable) deposit to be sent in with the registration to reserve your unit. Registration begins at 7:00 PM Friday night in Miss Kate’s Place. (32 units available) and the weekend ends after lunch on Sunday.

Send registration to: Circle C Ranch, 10451 Ashcraft Rd. | We accept VISA, Mastercard, and Discover as forms of payment. Delevan, NY 14042

For Office Use Only

RF_________________________________ PC_________________________________ DIS_________________________________

HF_________________________________ SC_________________________________ OB_________________________________

DUE________________________________ BK_________________________________

Health History: Check if any apply & explain. Use separate paper if necessaryo Diabetes o Seizures &/or Epilepsy o Heart defect/disorder

o Bedwetting o Emotional/Behavioral Disorder o Asthma

o Hay Fever o Bleeding/Clotting Disorder o Frequent Ear Infections

o Other:(specify) _________________________________________

Any Specific Activities to be Restricted __________________________

** ALLERGIES: (Explain reaction as well) Bees or Insect Bites/Stings ___________________________________

Foods (Specify) ___________________________________________

Other (Specify) ___________________________________________

Carries Epipen: ___________________________________________ /Or Inhaler: _____________________________________________

Penicillin: _______________________________________________Immunization History: Actual dates required by NYS Health Department up to age 21, A new copy is required each camp year. Photocopies are preferred.DPT _______ /______/_______/_____ Last Tetanus

Poliomyelitis______/______/_______ MMR_________/

Influenza B _________________ Hepatitis B ____________________

Varicella_______ Chicken Pox _________ Other _________________

The following standard over-the-counter medications are available at the nurse’s office and will be administered as needed at the discretion of an RN, ONLY if approval is indicated by the camper’s health care provider. Without this signature, the camper cannot be given any of these medications under New York State Law.

Drug Name Route Dr.’s Order CommentsCircle preferred formulation(s) Check one

Tylenol Chewable tablet / elixir oYes oNo Pain or Fever > _____ºFIbuprofen Chewable tablet / suspension oYes oNo Pain or Fever > _____ºF

Robitussin Cough & Cold Syrup oYes oNoPepto Bismol Liquid / chewable tablet oYes oNo For diarrhea, upset stomach

Benadryl Chewable tabs or pills oYes oNo Allergic reactionsOther oYes oNo

Health Care Provider’s Signature: __________________________________________

Parent or Guardian ______________________________________ Date __________

(Mr., Mrs., or Reverend)

Notarized: Sworn to me this _______ day of _______________, 20 ______.

Parent’s authorization for those under 18 years of age: In the event I cannot be reached in an emergency I hereby give permission to the physician selected by the camp to hospitalize, secure treatment and order injection, anaesthesia or surgery for my child as named above.* Our local hospitals, for immediate and efficient care in case of emergency, have requested that the Parent’s signature be notarized.

*The registration fee must be sent in with the Registration form in order to be fully Registered. The balance is to be paid on arrival at camp. Money must be in US currency- No Canadian cheques (checks).Camp is filled on a first come, first served basis. It is easierthat you make sure your friend registers at the

same time if you want to bunk together. **PLEASE NOTE: In the event of sickness or illness while at camp, the Parent/Guardian is responsible for all medical expenses incurred under the authori-zation of the Camp Registered Nurse and/or Director. These Claims may be submitted to your insurance provider when eligible for reimbursement.

****In the event of injury or accident while at camp, claims should be submit-ted to your insurance provider. Our camper insurance coverage (accidents or injury only) will be reimbursed you for medical claims which exceed the amount of your personal insurance plan provisions.

METHOD OF PAYMENT Do NOT send cash or checks,

Acceptable Methods of Payment: o Money Order (payable to Circle C Ranch)

Credit Card: o MasterCard o Visa o Discover o Phoned in Payment Total amount being paid $___________

Account Number ________________________________________________ Expiration Date ______________ Security Code _______

Signature ________________________________________________ Print Name ______________________________________

DISCOUNTS!Early Bird: If your registration is postmarked by May 1 you save $20 off your week at camp (Registration fee remains $75). If you’re too late, you can still save $10 by having your registration postmarked by June 1 (Registration fee remains $75).

Extra Week: Pay full price for your first week of camp and every other week you come you get $100 off!

Sibling Discount: When you pay full price for your first child ($305) you get $50 off your second child. If you have a big family, for every sibling after the first two you get $75 dollars off a piece! This discount is for immediate family members only, and cannot be used by cousins, nieces or nephews.

COSTS: Express Week: $75.00 plus $75 non-refundable registration fee. Total $150.00 (U.S. funds) Teen Week / Circle C Has Talent: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds) Regular Weeks Three-Seven: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds)

NOTE: NY State Law requires for horseback riding: 1. Shoes with heels. 2. Helmets (you may bring your own if it is Pony Club Approved)

TWO WAYS TO REGISTER: 1. Mail in the Registration Form and completed Health History with your

$75 registration fee to this address: Living Waters Circle C Ranch 10451 Ashcraft Rd., Delevan, NY 14042-9664 OR

2. Phone in your Registration information to our office and use a credit card (VISA, MASTERCARD, or DISCOVER) for payment of your $75 registration fee. Then, mail in your completed Registration Form and Health History to the above camp address. *We MUST receive this

within two weeks of your phone-in Registration. If we do not, your reservation will be cancelled. (The registration fee is nonrefundable.)

CONTACT INFORMATION: Phone Number (716) 492-3687 or 1-800-231-6866 Fax (716) 492-1361 E-mail: info@circlecranch.org Visit our website: www.circlecranch.org Office Hours: Monday-Friday 9-5 Messages taken by phone on off-hours are not guaranteed.

WHAT TO PACK: Upon receipt of your completed registration information, we will send you “Your Official Circle C Ranch ‘Get Ready for Camp’ checklist” along with your confirmation information.We are not responsible for lost articles

The Public Health Law Requires: 1. The camp be licensed by the NYS Dept. of Health 2. The camp to be inspected twice yearly 3. The inspection reports concerning the camp are filed with the Dept. of Health, 302, Laurens St., Olean, NY.

Rules for acceptance and participation in the program are the same for everyone without regard to race, color, or national origin. Any person who believes he/she has been discriminated against in any USDA-related activity should write immediately to the Secretary of Agriculture, Washington, DC 20250

Please indicate week attending:o Express Week $150/June 21-24

o Teen Week $305/June 26-July 1/Circle C’s Got Talent

o Week Three $305/July 3-8

o Week Four $305/July 10-15

o Week Five $305/July 17-22

o Week Six $305/July 24 – 29

o Week 7 $305/July 31-August 5

Must be checked to be registered. o Special Cookout $7.00

Prescription Route DosageSchedule & Indications

Comments

NOTARY SEAL

Every week of camp includes: Horseback riding, Lasertron, Rock wall climbing, Swimming, 60’ X 250’ giant slip-n-slide, Game room, Storm the Fort, Wild games and so much more!

WWW.C IRCL ECRANCH.ORG

familyCAMPAugust 11-13 A great weekend to have family adventures and make memories that will last a life time!! This one packs out quick, so don’t delay!!

If you want any more information you can check out our website (above) or you can download our app for your smart phone!

L i Fe iS GooD oN the Ranch.

June 27-July 2 / $305 / Ages 12+ Teen week is a wild adventure designed just for our teen campers. This year we will be having Circle C Has Talent: The Ultimate Lipsync Battle! You and your cabin will produce and perform an epic lipsync production as part of our competition. You will also be featured in our camp movie, complete with a premiere!

EXpREsSweek T EENweekJune 21-24 / $150 / Ages 8-18

A half week for all ages that is jam packed with as much fun and adventure as we could cram into it!

2017 CAMPER REGISTRATION & MEDICAL FORM(Please complete all information & type or print clearly)

Child’s Name ____________________________________________________________________________________________

Address ________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip _______________

E-Mail _________________________________________________________________________________________________

Date of Birth ____ /____ /_________ Sex o F o M Age ___ Weight ________ Current Grade Level ________________

I prefer to bunk with ________________________________________________ (bunk mates must be within one year of the same age)

Emergency Contacts

Home Phone Cell Phone Work Phone

FATHER’S NAME

MOTHER’S NAME

GUARDIAN

OTHER CONTACT

MEDICAL FORM Insurance Information: Name of Insurance Company: _________________________________________________________________________________

ID# _______________________________________________ Group # _____________________________________________

Policy# ____________________________________________ Certificate# ___________________________________________

Name Of Camper’s Physician: _____________________________ Phone #: ____________________________________________

Date of last Physical____/____/______

2017 FAMILY WEEKEND (August 12-14) REGISTRATION FORM (please type or print)

Adults: Ages 12 and up - $65.00 per person | Child: Ages 5-11 - $35.00 per person | * 4 years of age and under - FREEThis price includes a snack, 5 meals, 2 nights of lodging, and all the activities.

ADULTSName ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

CHILDREN:Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Address _________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip ________________

Phone:(____) _______________________________________ Cell (____) ___________________________________________

E-Mail __________________________________________________________________________________________________

There is a $50.00 (non-refundable) deposit to be sent in with the registration to reserve your unit. Registration begins at 7:00 PM Friday night in Miss Kate’s Place. (32 units available) and the weekend ends after lunch on Sunday.

Send registration to: Circle C Ranch, 10451 Ashcraft Rd. | We accept VISA, Mastercard, and Discover as forms of payment. Delevan, NY 14042

For Office Use Only

RF_________________________________ PC_________________________________ DIS_________________________________

HF_________________________________ SC_________________________________ OB_________________________________

DUE________________________________ BK_________________________________

Health History: Check if any apply & explain. Use separate paper if necessaryo Diabetes o Seizures &/or Epilepsy o Heart defect/disorder

o Bedwetting o Emotional/Behavioral Disorder o Asthma

o Hay Fever o Bleeding/Clotting Disorder o Frequent Ear Infections

o Other:(specify) _________________________________________

Any Specific Activities to be Restricted __________________________

** ALLERGIES: (Explain reaction as well) Bees or Insect Bites/Stings ___________________________________

Foods (Specify) ___________________________________________

Other (Specify) ___________________________________________

Carries Epipen: ___________________________________________ /Or Inhaler: _____________________________________________

Penicillin: _______________________________________________Immunization History: Actual dates required by NYS Health Department up to age 21, A new copy is required each camp year. Photocopies are preferred.DPT _______ /______/_______/_____ Last Tetanus

Poliomyelitis______/______/_______ MMR_________/

Influenza B _________________ Hepatitis B ____________________

Varicella_______ Chicken Pox _________ Other _________________

The following standard over-the-counter medications are available at the nurse’s office and will be administered as needed at the discretion of an RN, ONLY if approval is indicated by the camper’s health care provider. Without this signature, the camper cannot be given any of these medications under New York State Law.

Drug Name Route Dr.’s Order CommentsCircle preferred formulation(s) Check one

Tylenol Chewable tablet / elixir oYes oNo Pain or Fever > _____ºFIbuprofen Chewable tablet / suspension oYes oNo Pain or Fever > _____ºF

Robitussin Cough & Cold Syrup oYes oNoPepto Bismol Liquid / chewable tablet oYes oNo For diarrhea, upset stomach

Benadryl Chewable tabs or pills oYes oNo Allergic reactionsOther oYes oNo

Health Care Provider’s Signature: __________________________________________

Parent or Guardian ______________________________________ Date __________

(Mr., Mrs., or Reverend)

Notarized: Sworn to me this _______ day of _______________, 20 ______.

Parent’s authorization for those under 18 years of age: In the event I cannot be reached in an emergency I hereby give permission to the physician selected by the camp to hospitalize, secure treatment and order injection, anaesthesia or surgery for my child as named above.* Our local hospitals, for immediate and efficient care in case of emergency, have requested that the Parent’s signature be notarized.

*The registration fee must be sent in with the Registration form in order to be fully Registered. The balance is to be paid on arrival at camp. Money must be in US currency- No Canadian cheques (checks).Camp is filled on a first come, first served basis. It is easierthat you make sure your friend registers at the

same time if you want to bunk together. **PLEASE NOTE: In the event of sickness or illness while at camp, the Parent/Guardian is responsible for all medical expenses incurred under the authori-zation of the Camp Registered Nurse and/or Director. These Claims may be submitted to your insurance provider when eligible for reimbursement.

****In the event of injury or accident while at camp, claims should be submit-ted to your insurance provider. Our camper insurance coverage (accidents or injury only) will be reimbursed you for medical claims which exceed the amount of your personal insurance plan provisions.

METHOD OF PAYMENT Do NOT send cash or checks,

Acceptable Methods of Payment: o Money Order (payable to Circle C Ranch)

Credit Card: o MasterCard o Visa o Discover o Phoned in Payment Total amount being paid $___________

Account Number ________________________________________________ Expiration Date ______________ Security Code _______

Signature ________________________________________________ Print Name ______________________________________

DISCOUNTS!Early Bird: If your registration is postmarked by May 1 you save $20 off your week at camp (Registration fee remains $75). If you’re too late, you can still save $10 by having your registration postmarked by June 1 (Registration fee remains $75).

Extra Week: Pay full price for your first week of camp and every other week you come you get $100 off!

Sibling Discount: When you pay full price for your first child ($305) you get $50 off your second child. If you have a big family, for every sibling after the first two you get $75 dollars off a piece! This discount is for immediate family members only, and cannot be used by cousins, nieces or nephews.

COSTS: Express Week: $75.00 plus $75 non-refundable registration fee. Total $150.00 (U.S. funds) Teen Week / Circle C Has Talent: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds) Regular Weeks Three-Seven: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds)

NOTE: NY State Law requires for horseback riding: 1. Shoes with heels. 2. Helmets (you may bring your own if it is Pony Club Approved)

TWO WAYS TO REGISTER: 1. Mail in the Registration Form and completed Health History with your

$75 registration fee to this address: Living Waters Circle C Ranch 10451 Ashcraft Rd., Delevan, NY 14042-9664 OR

2. Phone in your Registration information to our office and use a credit card (VISA, MASTERCARD, or DISCOVER) for payment of your $75 registration fee. Then, mail in your completed Registration Form and Health History to the above camp address. *We MUST receive this

within two weeks of your phone-in Registration. If we do not, your reservation will be cancelled. (The registration fee is nonrefundable.)

CONTACT INFORMATION: Phone Number (716) 492-3687 or 1-800-231-6866 Fax (716) 492-1361 E-mail: info@circlecranch.org Visit our website: www.circlecranch.org Office Hours: Monday-Friday 9-5 Messages taken by phone on off-hours are not guaranteed.

WHAT TO PACK: Upon receipt of your completed registration information, we will send you “Your Official Circle C Ranch ‘Get Ready for Camp’ checklist” along with your confirmation information.We are not responsible for lost articles

The Public Health Law Requires: 1. The camp be licensed by the NYS Dept. of Health 2. The camp to be inspected twice yearly 3. The inspection reports concerning the camp are filed with the Dept. of Health, 302, Laurens St., Olean, NY.

Rules for acceptance and participation in the program are the same for everyone without regard to race, color, or national origin. Any person who believes he/she has been discriminated against in any USDA-related activity should write immediately to the Secretary of Agriculture, Washington, DC 20250

Please indicate week attending:o Express Week $150/June 21-24

o Teen Week $305/June 26-July 1/Circle C’s Got Talent

o Week Three $305/July 3-8

o Week Four $305/July 10-15

o Week Five $305/July 17-22

o Week Six $305/July 24 – 29

o Week 7 $305/July 31-August 5

Must be checked to be registered. o Special Cookout $7.00

Prescription Route DosageSchedule & Indications

Comments

NOTARY SEAL

Every week of camp includes: Horseback riding, Lasertron, Rock wall climbing, Swimming, 60’ X 250’ giant slip-n-slide, Game room, Storm the Fort, Wild games and so much more!

WWW.C IRCL ECRANCH.ORG

familyCAMPAugust 11-13 A great weekend to have family adventures and make memories that will last a life time!! This one packs out quick, so don’t delay!!

If you want any more information you can check out our website (above) or you can download our app for your smart phone!

L i Fe iS GooD oN the Ranch.

June 27-July 2 / $305 / Ages 12+ Teen week is a wild adventure designed just for our teen campers. This year we will be having Circle C Has Talent: The Ultimate Lipsync Battle! You and your cabin will produce and perform an epic lipsync production as part of our competition. You will also be featured in our camp movie, complete with a premiere!

EXpREsSweek T EENweekJune 21-24 / $150 / Ages 8-18

A half week for all ages that is jam packed with as much fun and adventure as we could cram into it!

2017 CAMPER REGISTRATION & MEDICAL FORM(Please complete all information & type or print clearly)

Child’s Name ____________________________________________________________________________________________

Address ________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip _______________

E-Mail _________________________________________________________________________________________________

Date of Birth ____ /____ /_________ Sex o F o M Age ___ Weight ________ Current Grade Level ________________

I prefer to bunk with ________________________________________________ (bunk mates must be within one year of the same age)

Emergency Contacts

Home Phone Cell Phone Work Phone

FATHER’S NAME

MOTHER’S NAME

GUARDIAN

OTHER CONTACT

MEDICAL FORM Insurance Information: Name of Insurance Company: _________________________________________________________________________________

ID# _______________________________________________ Group # _____________________________________________

Policy# ____________________________________________ Certificate# ___________________________________________

Name Of Camper’s Physician: _____________________________ Phone #: ____________________________________________

Date of last Physical____/____/______

2017 FAMILY WEEKEND (August 12-14) REGISTRATION FORM (please type or print)

Adults: Ages 12 and up - $65.00 per person | Child: Ages 5-11 - $35.00 per person | * 4 years of age and under - FREEThis price includes a snack, 5 meals, 2 nights of lodging, and all the activities.

ADULTSName ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

CHILDREN:Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Address _________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip ________________

Phone:(____) _______________________________________ Cell (____) ___________________________________________

E-Mail __________________________________________________________________________________________________

There is a $50.00 (non-refundable) deposit to be sent in with the registration to reserve your unit. Registration begins at 7:00 PM Friday night in Miss Kate’s Place. (32 units available) and the weekend ends after lunch on Sunday.

Send registration to: Circle C Ranch, 10451 Ashcraft Rd. | We accept VISA, Mastercard, and Discover as forms of payment. Delevan, NY 14042

For Office Use Only

RF_________________________________ PC_________________________________ DIS_________________________________

HF_________________________________ SC_________________________________ OB_________________________________

DUE________________________________ BK_________________________________

Health History: Check if any apply & explain. Use separate paper if necessaryo Diabetes o Seizures &/or Epilepsy o Heart defect/disorder

o Bedwetting o Emotional/Behavioral Disorder o Asthma

o Hay Fever o Bleeding/Clotting Disorder o Frequent Ear Infections

o Other:(specify) _________________________________________

Any Specific Activities to be Restricted __________________________

** ALLERGIES: (Explain reaction as well) Bees or Insect Bites/Stings ___________________________________

Foods (Specify) ___________________________________________

Other (Specify) ___________________________________________

Carries Epipen: ___________________________________________ /Or Inhaler: _____________________________________________

Penicillin: _______________________________________________Immunization History: Actual dates required by NYS Health Department up to age 21, A new copy is required each camp year. Photocopies are preferred.DPT _______ /______/_______/_____ Last Tetanus

Poliomyelitis______/______/_______ MMR_________/

Influenza B _________________ Hepatitis B ____________________

Varicella_______ Chicken Pox _________ Other _________________

The following standard over-the-counter medications are available at the nurse’s office and will be administered as needed at the discretion of an RN, ONLY if approval is indicated by the camper’s health care provider. Without this signature, the camper cannot be given any of these medications under New York State Law.

Drug Name Route Dr.’s Order CommentsCircle preferred formulation(s) Check one

Tylenol Chewable tablet / elixir oYes oNo Pain or Fever > _____ºFIbuprofen Chewable tablet / suspension oYes oNo Pain or Fever > _____ºF

Robitussin Cough & Cold Syrup oYes oNoPepto Bismol Liquid / chewable tablet oYes oNo For diarrhea, upset stomach

Benadryl Chewable tabs or pills oYes oNo Allergic reactionsOther oYes oNo

Health Care Provider’s Signature: __________________________________________

Parent or Guardian ______________________________________ Date __________

(Mr., Mrs., or Reverend)

Notarized: Sworn to me this _______ day of _______________, 20 ______.

Parent’s authorization for those under 18 years of age: In the event I cannot be reached in an emergency I hereby give permission to the physician selected by the camp to hospitalize, secure treatment and order injection, anaesthesia or surgery for my child as named above.* Our local hospitals, for immediate and efficient care in case of emergency, have requested that the Parent’s signature be notarized.

*The registration fee must be sent in with the Registration form in order to be fully Registered. The balance is to be paid on arrival at camp. Money must be in US currency- No Canadian cheques (checks).Camp is filled on a first come, first served basis. It is easierthat you make sure your friend registers at the

same time if you want to bunk together. **PLEASE NOTE: In the event of sickness or illness while at camp, the Parent/Guardian is responsible for all medical expenses incurred under the authori-zation of the Camp Registered Nurse and/or Director. These Claims may be submitted to your insurance provider when eligible for reimbursement.

****In the event of injury or accident while at camp, claims should be submit-ted to your insurance provider. Our camper insurance coverage (accidents or injury only) will be reimbursed you for medical claims which exceed the amount of your personal insurance plan provisions.

METHOD OF PAYMENT Do NOT send cash or checks,

Acceptable Methods of Payment: o Money Order (payable to Circle C Ranch)

Credit Card: o MasterCard o Visa o Discover o Phoned in Payment Total amount being paid $___________

Account Number ________________________________________________ Expiration Date ______________ Security Code _______

Signature ________________________________________________ Print Name ______________________________________

DISCOUNTS!Early Bird: If your registration is postmarked by May 1 you save $20 off your week at camp (Registration fee remains $75). If you’re too late, you can still save $10 by having your registration postmarked by June 1 (Registration fee remains $75).

Extra Week: Pay full price for your first week of camp and every other week you come you get $100 off!

Sibling Discount: When you pay full price for your first child ($305) you get $50 off your second child. If you have a big family, for every sibling after the first two you get $75 dollars off a piece! This discount is for immediate family members only, and cannot be used by cousins, nieces or nephews.

COSTS: Express Week: $75.00 plus $75 non-refundable registration fee. Total $150.00 (U.S. funds) Teen Week / Circle C Has Talent: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds) Regular Weeks Three-Seven: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds)

NOTE: NY State Law requires for horseback riding: 1. Shoes with heels. 2. Helmets (you may bring your own if it is Pony Club Approved)

TWO WAYS TO REGISTER: 1. Mail in the Registration Form and completed Health History with your

$75 registration fee to this address: Living Waters Circle C Ranch 10451 Ashcraft Rd., Delevan, NY 14042-9664 OR

2. Phone in your Registration information to our office and use a credit card (VISA, MASTERCARD, or DISCOVER) for payment of your $75 registration fee. Then, mail in your completed Registration Form and Health History to the above camp address. *We MUST receive this

within two weeks of your phone-in Registration. If we do not, your reservation will be cancelled. (The registration fee is nonrefundable.)

CONTACT INFORMATION: Phone Number (716) 492-3687 or 1-800-231-6866 Fax (716) 492-1361 E-mail: info@circlecranch.org Visit our website: www.circlecranch.org Office Hours: Monday-Friday 9-5 Messages taken by phone on off-hours are not guaranteed.

WHAT TO PACK: Upon receipt of your completed registration information, we will send you “Your Official Circle C Ranch ‘Get Ready for Camp’ checklist” along with your confirmation information.We are not responsible for lost articles

The Public Health Law Requires: 1. The camp be licensed by the NYS Dept. of Health 2. The camp to be inspected twice yearly 3. The inspection reports concerning the camp are filed with the Dept. of Health, 302, Laurens St., Olean, NY.

Rules for acceptance and participation in the program are the same for everyone without regard to race, color, or national origin. Any person who believes he/she has been discriminated against in any USDA-related activity should write immediately to the Secretary of Agriculture, Washington, DC 20250

Please indicate week attending:o Express Week $150/June 21-24

o Teen Week $305/June 26-July 1/Circle C’s Got Talent

o Week Three $305/July 3-8

o Week Four $305/July 10-15

o Week Five $305/July 17-22

o Week Six $305/July 24 – 29

o Week 7 $305/July 31-August 5

Must be checked to be registered. o Special Cookout $7.00

Prescription Route DosageSchedule & Indications

Comments

NOTARY SEAL

Every week of camp includes: Horseback riding, Lasertron, Rock wall climbing, Swimming, 60’ X 250’ giant slip-n-slide, Game room, Storm the Fort, Wild games and so much more!

FAMILY CAMP REGISTRATION AND DISCOUNT INFORMATION ON NEXT PAGE.

WWW.C IRCL ECRANCH.ORG

familyCAMPAugust 11-13 A great weekend to have family adventures and make memories that will last a life time!! This one packs out quick, so don’t delay!!

If you want any more information you can check out our website (above) or you can download our app for your smart phone!

L i Fe iS GooD oN the Ranch.

June 27-July 2 / $305 / Ages 12+ Teen week is a wild adventure designed just for our teen campers. This year we will be having Circle C Has Talent: The Ultimate Lipsync Battle! You and your cabin will produce and perform an epic lipsync production as part of our competition. You will also be featured in our camp movie, complete with a premiere!

EXpREsSweek T EENweekJune 21-24 / $150 / Ages 8-18

A half week for all ages that is jam packed with as much fun and adventure as we could cram into it!

2017 CAMPER REGISTRATION & MEDICAL FORM(Please complete all information & type or print clearly)

Child’s Name ____________________________________________________________________________________________

Address ________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip _______________

E-Mail _________________________________________________________________________________________________

Date of Birth ____ /____ /_________ Sex o F o M Age ___ Weight ________ Current Grade Level ________________

I prefer to bunk with ________________________________________________ (bunk mates must be within one year of the same age)

Emergency Contacts

Home Phone Cell Phone Work Phone

FATHER’S NAME

MOTHER’S NAME

GUARDIAN

OTHER CONTACT

MEDICAL FORM Insurance Information: Name of Insurance Company: _________________________________________________________________________________

ID# _______________________________________________ Group # _____________________________________________

Policy# ____________________________________________ Certificate# ___________________________________________

Name Of Camper’s Physician: _____________________________ Phone #: ____________________________________________

Date of last Physical____/____/______

2017 FAMILY WEEKEND (August 12-14) REGISTRATION FORM (please type or print)

Adults: Ages 12 and up - $65.00 per person | Child: Ages 5-11 - $35.00 per person | * 4 years of age and under - FREEThis price includes a snack, 5 meals, 2 nights of lodging, and all the activities.

ADULTSName ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

CHILDREN:Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Address _________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip ________________

Phone:(____) _______________________________________ Cell (____) ___________________________________________

E-Mail __________________________________________________________________________________________________

There is a $50.00 (non-refundable) deposit to be sent in with the registration to reserve your unit. Registration begins at 7:00 PM Friday night in Miss Kate’s Place. (32 units available) and the weekend ends after lunch on Sunday.

Send registration to: Circle C Ranch, 10451 Ashcraft Rd. | We accept VISA, Mastercard, and Discover as forms of payment. Delevan, NY 14042

For Office Use Only

RF_________________________________ PC_________________________________ DIS_________________________________

HF_________________________________ SC_________________________________ OB_________________________________

DUE________________________________ BK_________________________________

Health History: Check if any apply & explain. Use separate paper if necessaryo Diabetes o Seizures &/or Epilepsy o Heart defect/disorder

o Bedwetting o Emotional/Behavioral Disorder o Asthma

o Hay Fever o Bleeding/Clotting Disorder o Frequent Ear Infections

o Other:(specify) _________________________________________

Any Specific Activities to be Restricted __________________________

** ALLERGIES: (Explain reaction as well) Bees or Insect Bites/Stings ___________________________________

Foods (Specify) ___________________________________________

Other (Specify) ___________________________________________

Carries Epipen: ___________________________________________ /Or Inhaler: _____________________________________________

Penicillin: _______________________________________________Immunization History: Actual dates required by NYS Health Department up to age 21, A new copy is required each camp year. Photocopies are preferred.DPT _______ /______/_______/_____ Last Tetanus

Poliomyelitis______/______/_______ MMR_________/

Influenza B _________________ Hepatitis B ____________________

Varicella_______ Chicken Pox _________ Other _________________

The following standard over-the-counter medications are available at the nurse’s office and will be administered as needed at the discretion of an RN, ONLY if approval is indicated by the camper’s health care provider. Without this signature, the camper cannot be given any of these medications under New York State Law.

Drug Name Route Dr.’s Order CommentsCircle preferred formulation(s) Check one

Tylenol Chewable tablet / elixir oYes oNo Pain or Fever > _____ºFIbuprofen Chewable tablet / suspension oYes oNo Pain or Fever > _____ºF

Robitussin Cough & Cold Syrup oYes oNoPepto Bismol Liquid / chewable tablet oYes oNo For diarrhea, upset stomach

Benadryl Chewable tabs or pills oYes oNo Allergic reactionsOther oYes oNo

Health Care Provider’s Signature: __________________________________________

Parent or Guardian ______________________________________ Date __________

(Mr., Mrs., or Reverend)

Notarized: Sworn to me this _______ day of _______________, 20 ______.

Parent’s authorization for those under 18 years of age: In the event I cannot be reached in an emergency I hereby give permission to the physician selected by the camp to hospitalize, secure treatment and order injection, anaesthesia or surgery for my child as named above.* Our local hospitals, for immediate and efficient care in case of emergency, have requested that the Parent’s signature be notarized.

*The registration fee must be sent in with the Registration form in order to be fully Registered. The balance is to be paid on arrival at camp. Money must be in US currency- No Canadian cheques (checks).Camp is filled on a first come, first served basis. It is easierthat you make sure your friend registers at the

same time if you want to bunk together. **PLEASE NOTE: In the event of sickness or illness while at camp, the Parent/Guardian is responsible for all medical expenses incurred under the authori-zation of the Camp Registered Nurse and/or Director. These Claims may be submitted to your insurance provider when eligible for reimbursement.

****In the event of injury or accident while at camp, claims should be submit-ted to your insurance provider. Our camper insurance coverage (accidents or injury only) will be reimbursed you for medical claims which exceed the amount of your personal insurance plan provisions.

METHOD OF PAYMENT Do NOT send cash or checks,

Acceptable Methods of Payment: o Money Order (payable to Circle C Ranch)

Credit Card: o MasterCard o Visa o Discover o Phoned in Payment Total amount being paid $___________

Account Number ________________________________________________ Expiration Date ______________ Security Code _______

Signature ________________________________________________ Print Name ______________________________________

DISCOUNTS!Early Bird: If your registration is postmarked by May 1 you save $20 off your week at camp (Registration fee remains $75). If you’re too late, you can still save $10 by having your registration postmarked by June 1 (Registration fee remains $75).

Extra Week: Pay full price for your first week of camp and every other week you come you get $100 off!

Sibling Discount: When you pay full price for your first child ($305) you get $50 off your second child. If you have a big family, for every sibling after the first two you get $75 dollars off a piece! This discount is for immediate family members only, and cannot be used by cousins, nieces or nephews.

COSTS: Express Week: $75.00 plus $75 non-refundable registration fee. Total $150.00 (U.S. funds) Teen Week / Circle C Has Talent: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds) Regular Weeks Three-Seven: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds)

NOTE: NY State Law requires for horseback riding: 1. Shoes with heels. 2. Helmets (you may bring your own if it is Pony Club Approved)

TWO WAYS TO REGISTER: 1. Mail in the Registration Form and completed Health History with your

$75 registration fee to this address: Living Waters Circle C Ranch 10451 Ashcraft Rd., Delevan, NY 14042-9664 OR

2. Phone in your Registration information to our office and use a credit card (VISA, MASTERCARD, or DISCOVER) for payment of your $75 registration fee. Then, mail in your completed Registration Form and Health History to the above camp address. *We MUST receive this

within two weeks of your phone-in Registration. If we do not, your reservation will be cancelled. (The registration fee is nonrefundable.)

CONTACT INFORMATION: Phone Number (716) 492-3687 or 1-800-231-6866 Fax (716) 492-1361 E-mail: info@circlecranch.org Visit our website: www.circlecranch.org Office Hours: Monday-Friday 9-5 Messages taken by phone on off-hours are not guaranteed.

WHAT TO PACK: Upon receipt of your completed registration information, we will send you “Your Official Circle C Ranch ‘Get Ready for Camp’ checklist” along with your confirmation information.We are not responsible for lost articles

The Public Health Law Requires: 1. The camp be licensed by the NYS Dept. of Health 2. The camp to be inspected twice yearly 3. The inspection reports concerning the camp are filed with the Dept. of Health, 302, Laurens St., Olean, NY.

Rules for acceptance and participation in the program are the same for everyone without regard to race, color, or national origin. Any person who believes he/she has been discriminated against in any USDA-related activity should write immediately to the Secretary of Agriculture, Washington, DC 20250

Please indicate week attending:o Express Week $150/June 21-24

o Teen Week $305/June 26-July 1/Circle C’s Got Talent

o Week Three $305/July 3-8

o Week Four $305/July 10-15

o Week Five $305/July 17-22

o Week Six $305/July 24 – 29

o Week 7 $305/July 31-August 5

Must be checked to be registered. o Special Cookout $7.00

Prescription Route DosageSchedule & Indications

Comments

NOTARY SEAL

Every week of camp includes: Horseback riding, Lasertron, Rock wall climbing, Swimming, 60’ X 250’ giant slip-n-slide, Game room, Storm the Fort, Wild games and so much more!

WWW.C IRCL ECRANCH.ORG

familyCAMPAugust 11-13 A great weekend to have family adventures and make memories that will last a life time!! This one packs out quick, so don’t delay!!

If you want any more information you can check out our website (above) or you can download our app for your smart phone!

L i Fe iS GooD oN the Ranch.

June 27-July 2 / $305 / Ages 12+ Teen week is a wild adventure designed just for our teen campers. This year we will be having Circle C Has Talent: The Ultimate Lipsync Battle! You and your cabin will produce and perform an epic lipsync production as part of our competition. You will also be featured in our camp movie, complete with a premiere!

EXpREsSweek T EENweekJune 21-24 / $150 / Ages 8-18

A half week for all ages that is jam packed with as much fun and adventure as we could cram into it!

2017 CAMPER REGISTRATION & MEDICAL FORM(Please complete all information & type or print clearly)

Child’s Name ____________________________________________________________________________________________

Address ________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip _______________

E-Mail _________________________________________________________________________________________________

Date of Birth ____ /____ /_________ Sex o F o M Age ___ Weight ________ Current Grade Level ________________

I prefer to bunk with ________________________________________________ (bunk mates must be within one year of the same age)

Emergency Contacts

Home Phone Cell Phone Work Phone

FATHER’S NAME

MOTHER’S NAME

GUARDIAN

OTHER CONTACT

MEDICAL FORM Insurance Information: Name of Insurance Company: _________________________________________________________________________________

ID# _______________________________________________ Group # _____________________________________________

Policy# ____________________________________________ Certificate# ___________________________________________

Name Of Camper’s Physician: _____________________________ Phone #: ____________________________________________

Date of last Physical____/____/______

2017 FAMILY WEEKEND (August 12-14) REGISTRATION FORM (please type or print)

Adults: Ages 12 and up - $65.00 per person | Child: Ages 5-11 - $35.00 per person | * 4 years of age and under - FREEThis price includes a snack, 5 meals, 2 nights of lodging, and all the activities.

ADULTSName ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

CHILDREN:Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Address _________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip ________________

Phone:(____) _______________________________________ Cell (____) ___________________________________________

E-Mail __________________________________________________________________________________________________

There is a $50.00 (non-refundable) deposit to be sent in with the registration to reserve your unit. Registration begins at 7:00 PM Friday night in Miss Kate’s Place. (32 units available) and the weekend ends after lunch on Sunday.

Send registration to: Circle C Ranch, 10451 Ashcraft Rd. | We accept VISA, Mastercard, and Discover as forms of payment. Delevan, NY 14042

For Office Use Only

RF_________________________________ PC_________________________________ DIS_________________________________

HF_________________________________ SC_________________________________ OB_________________________________

DUE________________________________ BK_________________________________

Health History: Check if any apply & explain. Use separate paper if necessaryo Diabetes o Seizures &/or Epilepsy o Heart defect/disorder

o Bedwetting o Emotional/Behavioral Disorder o Asthma

o Hay Fever o Bleeding/Clotting Disorder o Frequent Ear Infections

o Other:(specify) _________________________________________

Any Specific Activities to be Restricted __________________________

** ALLERGIES: (Explain reaction as well) Bees or Insect Bites/Stings ___________________________________

Foods (Specify) ___________________________________________

Other (Specify) ___________________________________________

Carries Epipen: ___________________________________________ /Or Inhaler: _____________________________________________

Penicillin: _______________________________________________Immunization History: Actual dates required by NYS Health Department up to age 21, A new copy is required each camp year. Photocopies are preferred.DPT _______ /______/_______/_____ Last Tetanus

Poliomyelitis______/______/_______ MMR_________/

Influenza B _________________ Hepatitis B ____________________

Varicella_______ Chicken Pox _________ Other _________________

The following standard over-the-counter medications are available at the nurse’s office and will be administered as needed at the discretion of an RN, ONLY if approval is indicated by the camper’s health care provider. Without this signature, the camper cannot be given any of these medications under New York State Law.

Drug Name Route Dr.’s Order CommentsCircle preferred formulation(s) Check one

Tylenol Chewable tablet / elixir oYes oNo Pain or Fever > _____ºFIbuprofen Chewable tablet / suspension oYes oNo Pain or Fever > _____ºF

Robitussin Cough & Cold Syrup oYes oNoPepto Bismol Liquid / chewable tablet oYes oNo For diarrhea, upset stomach

Benadryl Chewable tabs or pills oYes oNo Allergic reactionsOther oYes oNo

Health Care Provider’s Signature: __________________________________________

Parent or Guardian ______________________________________ Date __________

(Mr., Mrs., or Reverend)

Notarized: Sworn to me this _______ day of _______________, 20 ______.

Parent’s authorization for those under 18 years of age: In the event I cannot be reached in an emergency I hereby give permission to the physician selected by the camp to hospitalize, secure treatment and order injection, anaesthesia or surgery for my child as named above.* Our local hospitals, for immediate and efficient care in case of emergency, have requested that the Parent’s signature be notarized.

*The registration fee must be sent in with the Registration form in order to be fully Registered. The balance is to be paid on arrival at camp. Money must be in US currency- No Canadian cheques (checks).Camp is filled on a first come, first served basis. It is easierthat you make sure your friend registers at the

same time if you want to bunk together. **PLEASE NOTE: In the event of sickness or illness while at camp, the Parent/Guardian is responsible for all medical expenses incurred under the authori-zation of the Camp Registered Nurse and/or Director. These Claims may be submitted to your insurance provider when eligible for reimbursement.

****In the event of injury or accident while at camp, claims should be submit-ted to your insurance provider. Our camper insurance coverage (accidents or injury only) will be reimbursed you for medical claims which exceed the amount of your personal insurance plan provisions.

METHOD OF PAYMENT Do NOT send cash or checks,

Acceptable Methods of Payment: o Money Order (payable to Circle C Ranch)

Credit Card: o MasterCard o Visa o Discover o Phoned in Payment Total amount being paid $___________

Account Number ________________________________________________ Expiration Date ______________ Security Code _______

Signature ________________________________________________ Print Name ______________________________________

DISCOUNTS!Early Bird: If your registration is postmarked by May 1 you save $20 off your week at camp (Registration fee remains $75). If you’re too late, you can still save $10 by having your registration postmarked by June 1 (Registration fee remains $75).

Extra Week: Pay full price for your first week of camp and every other week you come you get $100 off!

Sibling Discount: When you pay full price for your first child ($305) you get $50 off your second child. If you have a big family, for every sibling after the first two you get $75 dollars off a piece! This discount is for immediate family members only, and cannot be used by cousins, nieces or nephews.

COSTS: Express Week: $75.00 plus $75 non-refundable registration fee. Total $150.00 (U.S. funds) Teen Week / Circle C Has Talent: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds) Regular Weeks Three-Seven: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds)

NOTE: NY State Law requires for horseback riding: 1. Shoes with heels. 2. Helmets (you may bring your own if it is Pony Club Approved)

TWO WAYS TO REGISTER: 1. Mail in the Registration Form and completed Health History with your

$75 registration fee to this address: Living Waters Circle C Ranch 10451 Ashcraft Rd., Delevan, NY 14042-9664 OR

2. Phone in your Registration information to our office and use a credit card (VISA, MASTERCARD, or DISCOVER) for payment of your $75 registration fee. Then, mail in your completed Registration Form and Health History to the above camp address. *We MUST receive this

within two weeks of your phone-in Registration. If we do not, your reservation will be cancelled. (The registration fee is nonrefundable.)

CONTACT INFORMATION: Phone Number (716) 492-3687 or 1-800-231-6866 Fax (716) 492-1361 E-mail: info@circlecranch.org Visit our website: www.circlecranch.org Office Hours: Monday-Friday 9-5 Messages taken by phone on off-hours are not guaranteed.

WHAT TO PACK: Upon receipt of your completed registration information, we will send you “Your Official Circle C Ranch ‘Get Ready for Camp’ checklist” along with your confirmation information.We are not responsible for lost articles

The Public Health Law Requires: 1. The camp be licensed by the NYS Dept. of Health 2. The camp to be inspected twice yearly 3. The inspection reports concerning the camp are filed with the Dept. of Health, 302, Laurens St., Olean, NY.

Rules for acceptance and participation in the program are the same for everyone without regard to race, color, or national origin. Any person who believes he/she has been discriminated against in any USDA-related activity should write immediately to the Secretary of Agriculture, Washington, DC 20250

Please indicate week attending:o Express Week $150/June 21-24

o Teen Week $305/June 26-July 1/Circle C’s Got Talent

o Week Three $305/July 3-8

o Week Four $305/July 10-15

o Week Five $305/July 17-22

o Week Six $305/July 24 – 29

o Week 7 $305/July 31-August 5

Must be checked to be registered. o Special Cookout $7.00

Prescription Route DosageSchedule & Indications

Comments

NOTARY SEAL

Every week of camp includes: Horseback riding, Lasertron, Rock wall climbing, Swimming, 60’ X 250’ giant slip-n-slide, Game room, Storm the Fort, Wild games and so much more!

WWW.C IRCL ECRANCH.ORG

familyCAMPAugust 11-13 A great weekend to have family adventures and make memories that will last a life time!! This one packs out quick, so don’t delay!!

If you want any more information you can check out our website (above) or you can download our app for your smart phone!

L i Fe iS GooD oN the Ranch.

June 27-July 2 / $305 / Ages 12+ Teen week is a wild adventure designed just for our teen campers. This year we will be having Circle C Has Talent: The Ultimate Lipsync Battle! You and your cabin will produce and perform an epic lipsync production as part of our competition. You will also be featured in our camp movie, complete with a premiere!

EXpREsSweek T EENweekJune 21-24 / $150 / Ages 8-18

A half week for all ages that is jam packed with as much fun and adventure as we could cram into it!

2017 CAMPER REGISTRATION & MEDICAL FORM(Please complete all information & type or print clearly)

Child’s Name ____________________________________________________________________________________________

Address ________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip _______________

E-Mail _________________________________________________________________________________________________

Date of Birth ____ /____ /_________ Sex o F o M Age ___ Weight ________ Current Grade Level ________________

I prefer to bunk with ________________________________________________ (bunk mates must be within one year of the same age)

Emergency Contacts

Home Phone Cell Phone Work Phone

FATHER’S NAME

MOTHER’S NAME

GUARDIAN

OTHER CONTACT

MEDICAL FORM Insurance Information: Name of Insurance Company: _________________________________________________________________________________

ID# _______________________________________________ Group # _____________________________________________

Policy# ____________________________________________ Certificate# ___________________________________________

Name Of Camper’s Physician: _____________________________ Phone #: ____________________________________________

Date of last Physical____/____/______

2017 FAMILY WEEKEND (August 12-14) REGISTRATION FORM (please type or print)

Adults: Ages 12 and up - $65.00 per person | Child: Ages 5-11 - $35.00 per person | * 4 years of age and under - FREEThis price includes a snack, 5 meals, 2 nights of lodging, and all the activities.

ADULTSName ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

Name ______________________________________________

CHILDREN:Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Name/Age ___________________________________________

Address _________________________________________________________________________________________________

City _______________________________________________________________ State or Prov. ______ Zip ________________

Phone:(____) _______________________________________ Cell (____) ___________________________________________

E-Mail __________________________________________________________________________________________________

There is a $50.00 (non-refundable) deposit to be sent in with the registration to reserve your unit. Registration begins at 7:00 PM Friday night in Miss Kate’s Place. (32 units available) and the weekend ends after lunch on Sunday.

Send registration to: Circle C Ranch, 10451 Ashcraft Rd. | We accept VISA, Mastercard, and Discover as forms of payment. Delevan, NY 14042

For Office Use Only

RF_________________________________ PC_________________________________ DIS_________________________________

HF_________________________________ SC_________________________________ OB_________________________________

DUE________________________________ BK_________________________________

Health History: Check if any apply & explain. Use separate paper if necessaryo Diabetes o Seizures &/or Epilepsy o Heart defect/disorder

o Bedwetting o Emotional/Behavioral Disorder o Asthma

o Hay Fever o Bleeding/Clotting Disorder o Frequent Ear Infections

o Other:(specify) _________________________________________

Any Specific Activities to be Restricted __________________________

** ALLERGIES: (Explain reaction as well) Bees or Insect Bites/Stings ___________________________________

Foods (Specify) ___________________________________________

Other (Specify) ___________________________________________

Carries Epipen: ___________________________________________ /Or Inhaler: _____________________________________________

Penicillin: _______________________________________________Immunization History: Actual dates required by NYS Health Department up to age 21, A new copy is required each camp year. Photocopies are preferred.DPT _______ /______/_______/_____ Last Tetanus

Poliomyelitis______/______/_______ MMR_________/

Influenza B _________________ Hepatitis B ____________________

Varicella_______ Chicken Pox _________ Other _________________

The following standard over-the-counter medications are available at the nurse’s office and will be administered as needed at the discretion of an RN, ONLY if approval is indicated by the camper’s health care provider. Without this signature, the camper cannot be given any of these medications under New York State Law.

Drug Name Route Dr.’s Order CommentsCircle preferred formulation(s) Check one

Tylenol Chewable tablet / elixir oYes oNo Pain or Fever > _____ºFIbuprofen Chewable tablet / suspension oYes oNo Pain or Fever > _____ºF

Robitussin Cough & Cold Syrup oYes oNoPepto Bismol Liquid / chewable tablet oYes oNo For diarrhea, upset stomach

Benadryl Chewable tabs or pills oYes oNo Allergic reactionsOther oYes oNo

Health Care Provider’s Signature: __________________________________________

Parent or Guardian ______________________________________ Date __________

(Mr., Mrs., or Reverend)

Notarized: Sworn to me this _______ day of _______________, 20 ______.

Parent’s authorization for those under 18 years of age: In the event I cannot be reached in an emergency I hereby give permission to the physician selected by the camp to hospitalize, secure treatment and order injection, anaesthesia or surgery for my child as named above.* Our local hospitals, for immediate and efficient care in case of emergency, have requested that the Parent’s signature be notarized.

*The registration fee must be sent in with the Registration form in order to be fully Registered. The balance is to be paid on arrival at camp. Money must be in US currency- No Canadian cheques (checks).Camp is filled on a first come, first served basis. It is easierthat you make sure your friend registers at the

same time if you want to bunk together. **PLEASE NOTE: In the event of sickness or illness while at camp, the Parent/Guardian is responsible for all medical expenses incurred under the authori-zation of the Camp Registered Nurse and/or Director. These Claims may be submitted to your insurance provider when eligible for reimbursement.

****In the event of injury or accident while at camp, claims should be submit-ted to your insurance provider. Our camper insurance coverage (accidents or injury only) will be reimbursed you for medical claims which exceed the amount of your personal insurance plan provisions.

METHOD OF PAYMENT Do NOT send cash or checks,

Acceptable Methods of Payment: o Money Order (payable to Circle C Ranch)

Credit Card: o MasterCard o Visa o Discover o Phoned in Payment Total amount being paid $___________

Account Number ________________________________________________ Expiration Date ______________ Security Code _______

Signature ________________________________________________ Print Name ______________________________________

DISCOUNTS!Early Bird: If your registration is postmarked by May 1 you save $20 off your week at camp (Registration fee remains $75). If you’re too late, you can still save $10 by having your registration postmarked by June 1 (Registration fee remains $75).

Extra Week: Pay full price for your first week of camp and every other week you come you get $100 off!

Sibling Discount: When you pay full price for your first child ($305) you get $50 off your second child. If you have a big family, for every sibling after the first two you get $75 dollars off a piece! This discount is for immediate family members only, and cannot be used by cousins, nieces or nephews.

COSTS: Express Week: $75.00 plus $75 non-refundable registration fee. Total $150.00 (U.S. funds) Teen Week / Circle C Has Talent: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds) Regular Weeks Three-Seven: $230.00 plus $75 non-refundable registration fee. Total $305.00 (U.S. funds)

NOTE: NY State Law requires for horseback riding: 1. Shoes with heels. 2. Helmets (you may bring your own if it is Pony Club Approved)

TWO WAYS TO REGISTER: 1. Mail in the Registration Form and completed Health History with your

$75 registration fee to this address: Living Waters Circle C Ranch 10451 Ashcraft Rd., Delevan, NY 14042-9664 OR

2. Phone in your Registration information to our office and use a credit card (VISA, MASTERCARD, or DISCOVER) for payment of your $75 registration fee. Then, mail in your completed Registration Form and Health History to the above camp address. *We MUST receive this

within two weeks of your phone-in Registration. If we do not, your reservation will be cancelled. (The registration fee is nonrefundable.)

CONTACT INFORMATION: Phone Number (716) 492-3687 or 1-800-231-6866 Fax (716) 492-1361 E-mail: info@circlecranch.org Visit our website: www.circlecranch.org Office Hours: Monday-Friday 9-5 Messages taken by phone on off-hours are not guaranteed.

WHAT TO PACK: Upon receipt of your completed registration information, we will send you “Your Official Circle C Ranch ‘Get Ready for Camp’ checklist” along with your confirmation information.We are not responsible for lost articles

The Public Health Law Requires: 1. The camp be licensed by the NYS Dept. of Health 2. The camp to be inspected twice yearly 3. The inspection reports concerning the camp are filed with the Dept. of Health, 302, Laurens St., Olean, NY.

Rules for acceptance and participation in the program are the same for everyone without regard to race, color, or national origin. Any person who believes he/she has been discriminated against in any USDA-related activity should write immediately to the Secretary of Agriculture, Washington, DC 20250

Please indicate week attending:o Express Week $150/June 21-24

o Teen Week $305/June 26-July 1/Circle C’s Got Talent

o Week Three $305/July 3-8

o Week Four $305/July 10-15

o Week Five $305/July 17-22

o Week Six $305/July 24 – 29

o Week 7 $305/July 31-August 5

Must be checked to be registered. o Special Cookout $7.00

Prescription Route DosageSchedule & Indications

Comments

NOTARY SEAL

Every week of camp includes: Horseback riding, Lasertron, Rock wall climbing, Swimming, 60’ X 250’ giant slip-n-slide, Game room, Storm the Fort, Wild games and so much more!

Living Waters Ministries10451 Ashcraft Rd.Delevan, NY 14042