• Summer Day Camp/Immersion Registration Form

    Summer Day Camp/Immersion Registration Form

    These forms are required for your child to attend camp.

  • Camper's Information

  • Date of Birth*
     / /

  • NOTE - Children need to have completed Kindergarten before they are eligible to participate in traditional day camp. 

  • First Day at Camp
     - -

  • Parents' Information

    Parent/Guardian 1
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Where would you like to be reached while your child is at camp?*

  • Parents’ Information

    Parent/Guardian 2
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Where would parent/guardian 2 like to be reached while your child is at camp?

  • Emergency Contacts/Authorized Pickup

    Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.

  • Heading

    Emergency Contact #1
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Heading

    Emergency Contact #2
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Medical / Health Information

  •  -
  • Is the Camper up-to-date on all immunizations?*
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  • Date of Last Tetanus or Diphtheria, Tetanus, Pertussis (DTaP) Vaccine?
     - -
  • Does your child have any food, medication or environmental allergies?*
  • Allergies? Check all that apply*
  • 0/150
  • Does your child’s allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child?*
  • Does your child have a special health or medical condition?*
  • 0/150
  • Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during child care hours?*
  • Is your child currently using any medication, food supplement or medical food (such as electrolyte solution)?*
  • 0/150
  • If yes, does this medication, food supplement, or medical food need to be administered at the day camp?*
  • Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?*
  • 0/150
  • Does this dietary restriction require a modified diet that eliminates all types of fluid milk or an entire food group?*
  • 0/200
  • 0/200

  • Additional Medication

  • Check all that apply

  • If your child's medication meets any of these criteria:

    1. A physician's instruction is needed for a nonprescription medication (e.g. child is underage or underweight per the label instructions); or
    2. It is a sample medication without a prescription label; or
    3. The nonprescription medication is to be given longer than three consecutive days within a fourteen day period or is a topical product or lotion that is being used for a skin ailment and is to be given no longer than fourteen consecutive days; or
    4. The child is on a modified diet (an entire food group is eliminated); or
    5. The medication contains codeine or aspirin.

    ***The topical product or lotion and the physician's instructions exceed the manufacturer's instructions or use

     

  • Upload a File
    Cancelof

  • Payment and Statement of Understanding

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      Total $0.00

      Credit Card
    • Acknowledgement of Policies and Procedures I have reviewed and received a copy of the center's policies and procedures/handbook.*
    • Date Signed*
       - -
    • Should be Empty: