CSS Neuse Foundation’s School of the Ironclad Sailor
Full Name: ___________________________________________________
Street Address: _______________________________________________
State:______Zip Code__________E-Mail Address:___________________
Gender: _______Male_______Female
Date of Birth: __________________
Parent or Guardian with whom the student lives: ____________________
Parent/Guardian Work or Emergency Contact Phone Number: __________
Required Medical Information
Date of Last Tetanus Booster: _____________________________________
Prescribed Medication Taken, if any: _______________________________
Reason for Taking Medication: ____________________________________
Specific Allergies (including type of reaction): ___________________________________________________________________________________
Insurance Information (Group, Plan Number & Phone number). Please attach copy of insurance Card
____________________________________________________________________________________________
Medical Release Form
Registration cannot be processed without the signature of the camper’s parent or guardian on this release form.
In case of medical emergency, I understand every effort will be made to contact parents or guardians of students. In the event that I cannot be reached, I hereby give permission to the physician selected by the CSS Neuse Foundation to hospitalize; secure for treatments; and order injection, anesthesia, or surgery for my child as named I also understand that the CSS Neuse Foundation reserves the right to review any information given and determine student capability based upon that information.
Parent or Guardian’s Signature____________________________________________________________Date:______________________
Payment Information
Payment is due when your completed application is submitted. The cost for lunch and all activities is $199 for each student. Make checks payable to CSS Neuse Foundation, and mail to: Post Office Box 251, Kinston, NC 28502. When your registration is received and processed, you will receive a confirmation email or phone, followed by details regarding activities.
Registration Deadline: August 1, 2008
