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Early Bird Super Kids Application

Camper Information
Enter Camper Name
Enter Member Number
Check Registration Grade
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Enter your Street Address
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Enter Zip Code (12345)
Enter Home Phone Number (xxx-xxx-xxxx)
Select Birth Date
Enter Upcoming School Grade
Parent Information
Enter Mother's Name
Enter Cell Number
Enter Mother's Work Number
Enter Father's Name
Enter Cell Number
Enter Father's Work Number
Specify Email Address
Emergency Contact Information

Wilson Country Club will only release campers to the custody of their parent(s) or legal guardians unless there is a prior notification in writing.

By filling in this form, you authorize Wilson Country Club to release your child, a minor, only to the care of the below listed emergency contacts.

Enter Name of Emergency Contact
Enter Relationship With Emergency Contact
Enter Phone of Emergency Contact
Enter Name of Emergency Contact
Enter Relationship With Emergency Contact
Enter Phone of Emergency Contact
Enter Name of Emergency Contact
Enter Relationship With Emergency Contact
Enter Phone of Emergency Contact

 

Enter Physician's Name
Enter Phone Number
List any Allergies
SESSION ENROLLMENT

(please check all session dates you are enrolling for)

Super Kids is available for Campers between the grades of Kindergarten and 7th grade

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Terms of Enrollment

This enrollment is not valid unless signed by a parent or guardian, and accepted by Wilson Country Club. Due to the seasonal nature of summer camps and the set limitation on spaces offered, no refund shall be provided for absences, changes, withdrawals, or dismissal for cause up to one week prior to the camp session. For the safety and general welfare of all campers, the Camp reserves the right to dismiss a camper whose conduct or influence, in the opinion of the director, is detrimental to the best interests of the Camp. Camp is not responsible for the loss of clothing, equipment, or other personal belongings. Camp reserves the right to use photographs/videos of campers for promotional purposes, and the parent/guardian authorizes such use without compensation. With this application, permission is granted for the enrolled camper to participate in all activates.

Medical Permission Statement

I hereby give Wilson Country Club permission to take my child to any hospital facility or outside doctor when deemed necessary. Furthermore, I hereby give permission to such hospital or outside doctor to authorize x-rays and emergency treatment if deemed necessary. I understand that all medical bills are my responsibility.

Release and Hold Harmless Statement

Participation in any Super Kids activities and use of any recreational facilities involves a risk of accidental injury despite all safety precautions. I as parent or guardian of the participant named herein, assume all risks and hazards incidental to the activities, and release from responsibility and agree to indemnify and hold harmless Wilson Country Club, its officers, directors, independent contractors, and all employees for any illness or injury to me or my children or family members occurring during his/her/our participation in any camp activities, trips, or use of any recreational facilities conducted by Wilson Country Club.

I have read the Terms of Agreement, the Medical Permission and Hold Harmless statements above and understand their terms and accept their conditions. In the event that this Agreement is executed by one parent, I acknowledge that I am also acting as the agent of the other parent with authority to so enroll my child at Super Kids and to execute this agreement upon the representations herein made in accepting this enrollment.

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Opening Hours

Mon-Fri 8:30am - 4:30pm

Contact Us

4509 Country Club Dr
Wilson, NC 27896
(252) 291-3815