Call us today!  845-356-1900

·

·

·

·

·

·

·

·

·

·

·

·

·

·

·

Drinks and is open to Members & Non-Members

Due to overwhelming popularity and to ensure proper supervision of the mini-camp program enrollment will be limited. Please register early to ensure a day of healthy fun for your children. Walk-ins on the day will only be available if space permits!
Book Early!

LifePlex Camp Registration Form
845-356-1900  fax 845-356-1850
www.lifeplexhealthclub.com

*EARLY DROP OFFS AND LATE PICK UPS ARE AVAILABLE!!*

Does your child take any prescription medication?

*If yes, please list _____________________________

___________________________________________

Does your child have any allergies?

*If yes, please list _____________________________

___________________________________________

Credit card Type:

Credit Card # _____________________________________ Exp. Date ______________

Billing Address for above credit card _________________________________________

________________________________________________________________________

I hereby give LifePlex Health Club LLC permission to charge my above listed credit card for payment of my accounts(s). I understand and accept the terms contained in this registration form. I also understand that no refunds will be made for absences of any kind. LifePlex is not responsible for any camper’s belongings lost or damaged at camp.
Refunds in full will be made until January 31st 2008.

________________________________________________________________________

Card Holders Signature

The undersigned warrants that my child has no disability or impairment that prevents him/her from participating in all camp activities. This representation is made by me knowing that LifePlex Health Club (Club) will rely upon it in allowing the child to participate in camp activities. I hereby giver permission to the camp director or other authorized personnel select a doctor, emergency medical personnel and/or a medical treatment facility who will provide medical healthcare and administer medication to my child when needed. Further, in the event I cannot be contacted in an emergency, I hereby give LifePlex Camp’s selected doctor, emergency medical personnel and/or medical treatment facility permission to secure and administer treatment including hospitalization for my child. I consent to any pictures of my child taken during camp will become the property of the Club. They may be used by the Club for promotional purposes without the payment of fees or other compensations to anyone. I understand and agree that upon acceptance of this application, we as parents/guardians assume all risk of injury to our child while at camp including but not limited to injury arising out of his/her transportation in connection with camp activities. I on behalf of the minor child, myself, my executors, administrators, heirs, assigns, and successors, hereby fully and forever release and discharge the Club, its agents, its owners, officers, employees, and management from all such claims, demands, injuries, actions or causes of action. I acknowledge and understand the terms contained in this application. LifePlex LLC has the right to suspend and/or terminate any camper for nonpayment of any fees as agreed or for inappropriate behavior incidental to the enjoyment or operation of camp. No refunds will be allowed.

________________________________________________________________________

Signature of Parent or legal Guardian