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

Name of Camper:
Age (at camp 2010):
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 to 11
Sunday, June 27 - Friday, July 9
2nd Session: Ages 12 to 13
Sunday, July 11 - Friday, July 23
3rd Session: Ages 14 to 15
 Sunday, July 25 - Friday, August 6
4th Session: Age 16
 Sunday, August 8 - Friday, August 20
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.