The Edward J. Madden Open Hearts Camp
250 Monument Valley Road, Great Barrington, Massachusetts 01230
413-528-2229

Name of Camper:
Age (at camp 2012):
Address:
Date of Birth:
Gender:
 Female Male
# of years previously at M.O.H.C.
Name of Parent or Guardian:
Email:
Address:
Phone: home work cell

Please indicate according to AGE the camp session in which you wish to enroll your child.

1st Session: Ages 8, 9 & 10
Sunday, June 24 - Friday, July 6
2nd Session: Ages 11 & 12
Sunday, July 8 - Friday, July 20
3rd Session: Ages 13 & 14
 Sunday, July 22 - Friday, August 3
4th Session: Ages 15 & 16
 Sunday, August 5 - Friday, August 17
All sessions are $250 and will be due in the Spring.
Cardiologist Name:
Phone:
Email:
Address:
Please give a brief summary of child’s present health:
use the back of the page if you need to
Yes, I authorize the use of photographs/video of my child while at camp
for promotional purposes only.

Please print, fill out and send to the address at the top of the page.