Form Center

1. Step One This section is complete This section is incomplete
2. Parent/Guardian Information This section is complete This section is incomplete
3. Swimming Information & Special Instructions This section is complete This section is incomplete
4. Permission Agreement This section is complete This section is incomplete

Step One

Camp Medical Form
One form per child is required on the first day of camp. Medical forms are destroyed at completion of camp.
Full Name of Child*
Birth Date*
Birth Date
Age*
(as of first day of camp)
Sex*
1. Male
2. Female
Allergies
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Parent/Guardian Name*
Address*
Other Parent/Guardian Name
Other Parent/Guardian Address
Home Phone Number
Cell Phone Number
Work Phone Number
Health Care Number*
Family Doctor*
Media Permission*
Local media or department staff may photograph or video record participants for promotional purposes. Do you give permission for your child to appear in these photos/videos?
1. Yes
1. No
Persons Authorized to Pick Up Child and/or Contact in Case of Emergency
(in addition to parents)
Authorized Person No. 1
Phone Number
Relationship
Authorized Person No. 2
Phone Number
Relationship
Authorized Person No. 3
Phone Number
Relationship
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Please read carefully and complete the following question on swimming information.
Swimming Level
Camp Swimmer Criteria (PDF)
To help our leaders ensure the safety of your child in the water, please read these criteria and determine if your child is a strong swimmer (green), moderate swimmer (yellow), or weak swimmer (red). Please indicate the child's swimming level in the following question.
Please indicate your child's swimming level.*
1. Green
2. Yellow
3. Red
4. Unsure
Special Instructions
In addition to swimming level, please provide the following information to help us ensure the safety of your child.
Are there any specific instructions concerning care, medication, diet, allergies, etc.?*
1. Yes
2. No
If yes, please specify these special instructions.
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Electronic Signature Agreement*
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Permission
I understand my child will participate in a number of recreation activities, both on site and off site, while they are registered in camp, and give them permission to participate. I also understand that children may be transported to these activities via bus or walking. In case of an emergency, I authorize camp leaders to seek medical attention for my child, including calling an ambulance and/or emergency contact person(s), as listed on the front of this form.
Electronic Signature*
Date*
Date

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