FAMILY DAY CAMP

August 7 OR 8, 2021

Camp Sertoma for Deaf and Hard of Hearing Children

Held at Millstone 4-H Camp Center

1296 Mallard Drive

Ellerbe, NC 28338

Registrations can be submitted online here or mailed to:

Camp Sertoma

c/o Sandy Waterman, Registration Coordinator

2923 Roderick Road, Frederick MD 21704

Tel: 301-620-2254 (voice message only)

Email: sertomadeafcamp@gmail.com

Save a stamp, apply online right here!

PLEASE NOTE: THIS IS LIMITED ONLY TO CAMPERS WHO WERE REGISTERED FOR THE 2020 CAMP AND THEIR FAMILY MEMBERS

Register by July 10 to reserve your space!

Camper Information

Which day will you attend? *

Saturday, August 7

Sunday, August 8

Camper First Name *

Camper Last Name *

Gender *

Birth Date * +

Address *

City, State, Zip *

Parent/Guardian Name *

Parent/Guardian Cell Phone *

Parent/Guardian Home Phone *

Parent/Guardian Email Address *

Is Parent:? *

Hearing

Deaf

Was this child registered for Camp Sertoma in 2020? *

Yes

No

Is this child: *

Deaf

Hard of Hearing

Cochlear Implant

Hearing Aid

Signing CODA* (please indicate deaf relative's name and relationship to child) Signing CODA* (please indicate deaf relative's name and relationship to child)

Please indicate child's method of communication(check all that apply, including for CODA children): *

Verbal (English)

ASL

Other (please describe) Other (please describe)

What is your child's t-shirt size? *

Family Members

Total number of family members attending day camp:

Name of Parent Attending

Name of Second Parent Attending (leave blank if only one parent is joining)

Name of Additional Child Attending

T-shirts will be provided to 2020 campers at no cost. Additional shirts are available for purchase by family members for $10 each. If you are interested in ordering a t-shirt (you can pay at camp, no need to pay in advance), please indicate the size and number of shirts in each size that you would like to reserve. *

Fees

Fees are $10/adult and $5/child. This includes all activities and lunch. Would you like us to email you an invoice or do you prefer to mail a check?

Please send me an invoice

I will mail a check

Camp Sertoma will have spoken English and ASL/sign language interpreters. Please indicate if your family has any other communication access needs.

Fees are all-inclusive for the day and cover lunch, breaks, and all activities. Camp Sertoma and Millstone 4-H Camp do not provide accidental injury insurance for this event. The undersigned agrees to abide by all Camp Sertoma and Millstone 4-H Camp rules and regulations, to be shared during registration; to indemnify and hold harmless Camp Sertoma and Millstone 4-H Camp, their agents and employees from and against any damage to person or property of anyone attending; to assume full responsibility for intentional damage to the facility, fixtures, or equipment of the camp.