I am the parent of ___________________________. I have read and understand the Privacy Policy of Camp Waziyatah, Inc., and its information practices with regard to children, as set forth on its web site. I hereby authorize my child to provide personal information to Camp Waziyatah, and I hereby authorize camp Waziyatah to use that information, for the following purpose ( check the ones that apply):

____To obtain information about the camp.
____To find out if the Camp has room for my child for the next camping season.
____To post messages on Otterchat, the Camp's online chat room.
____To submit an application for my child to attend the Camp.

Dated:____________ ___________, 2000

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Witness' Signature Parent's Signature

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Typed/Printed Name Typed/Printed Name

Fax to 508-668-2665