Please give us your emergency contact and carpool information below.
All medical information and agreement to the code of conduct listed below is required.
A confirmation email will be mailed to you within 24 hours. Thank you.
CAMPER INFORMATION
Child's name:
Last name:
First name:
Email registration confirmation to:
I attest that my child is in good physical and mental health. Any special considerations are indicated below. In case of accident or illness, I hereby give permission that my child may be given emergency treatment.
Parent/Guardian Name:
Daytime Phone:
CellPhone:
Evening Phone:
Alternate Emergency Contact:
Name:
Relationship:
Address:
Daytime Phone:
City:
Zip:
Cell Phone:
1. Allergies
Yes
No
Please list allergies below.
Please be specific as to the severity.
2. My child may have sunscreen applied during the day:
Yes
No
3. My child may partake of the peanut-free camp snack
with no restrictions.
(If NO, please provide daily snack for your child.)
Yes
No
4. Does your child routinely require Medication?
Yes
No
Please list medical concerns
5. Other concerns:
Carpool/Pick-up Authorizations
I hereby authorize the following individuals to pick up my child
(Please do not list names listed above):
Name:
Relationship:
Address:
Daytime Phone:
City:
Zip:
Cell Phone:
Name:
Relationship:
Address:
Daytime Phone:
City:
Zip:
Cell Phone:
NOTE: Written notification by parents or guardian MUST be given for pick-up by someone other than persons listed. Please let us know in advance if there are any issues regarding pick-up/drop-off of which we should be aware.
I understand that by completing and submitting this form via electronic transmission that I acknowledge the above statements and my submission of this form on-line shall substitute for and have the same legal effect as an original form signature.
Name:
Date