High School Registration Form - Camp Keep printable pdf download

(COUNSELOR CONTRACT

Office of Christine Lizardi Frazier

(UNDER 18 YEARS

ON BACK - PLEASE SIGN)

Kern County Superintendent of Schools

OF AGE)

1300 17th Street - CITY CENTRE

Bakersfield, CA 93301-4533

KEEP* HIGH SCHOOL REGISTRATION FORM

*KEEP (Kern Environmental Education Program)

Registration constitutes permission for your child to participate in all activities at KEEP operated by the Kern County Superintendent of Schools.

Name: _______________________________

Parent/Guardian#1: ____________________

Parent/Guardian#2: _____________________

Date of Birth: _________________________

Home Phone#1: ______________________

Home Phone#2: _______________________

Dates at KEEP: ________________________

Work Phone#1: _______________________

Work Phone#2: ________________________

School: _______________________________

Cell Phone#1: ________________________

Cell Phone#2 _________________________

Teacher: ______________________________

Home Address#1: _____________________

Home Address#2 ______________________

____________________________________

_____________________________________

SPECIAL HEALTH INFORMATION:

1. If yes to any of these special health care conditions, complete "Physician's Authorization to Attend" Form. Also, contact Assistant

Superintendent Desiree VonFlue (661-636-4629) and notify your child's teacher immediately to arrange a medical shadow.

a. Medications requiring injections or suppositories . . . . . . q No q Yes Comments: ___________________________________________

b. Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . q No q Yes Comments: __________________________________________

c. Severe food or nut allergy (requiring Epipen) . . . . . . . . . . . q No q Yes Comments: __________________________________________

d. Severe asthma requiring daily nebulizer use. . . . . . . . . . . . . q No q Yes Comments: __________________________________________

e. Respiratory Restrictions (i.e. limiting activity). . . . . . . . . . . . q No q Yes Comments: __________________________________________

f. Severe bee sting reaction (requiring Epipen) . . . . . . . . . . . . q No q Yes Comments: __________________________________________

g. Mobility limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . q No q Yes Comments: __________________________________________

h. Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . q No q Yes Comments: __________________________________________

i. Recent hospitalization or surgery . . . . . . . . . . . . . . . . . . . . . q No q Yes Comments: __________________________________________

j. Other serious health conditions. . . . . . . . . . . . . . . . . . . . . . q No q Yes If yes, describe ________________________________________

GENERAL HEALTH INFORMATION:

2. Is your child currently taking medication? . . . . . . . . . . . . . . . . . q No q Yes If yes, complete KEEP Pupil Medication Form.

3. Health condition that would limit outdoor activity:

a. Recent illness or exposure to illness? . . . . . . . . . . . . . . . . . . q No q Yes Comments: __________________________________________

b. Recent broken bones, sprains, etc.? . . . . . . . . . . . . . . . . . . . q No q Yes Comments: __________________________________________

c. Asthma? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . q No q Yes Comments: __________________________________________

d. Heart condition, other physical limitations? . . . . . . . . . . . . . q No q Yes Comments: __________________________________________

4. Other factors that may affect the care of your child? . . . . . . . . q No q Yes Comments: __________________________________________

5. Allergy and Dietary Information:

a. Vegetarian. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . q No q Yes Comments: __________________________________________

b. Food Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . q No q Yes Comments: __________________________________________

c. Medication Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . q No q Yes Comments: __________________________________________

d. Insect Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . q No q Yes Comments: __________________________________________

e. Other Allergy and Dietary Concerns . . . . . . . . . . . . . . . . . . q No q Yes If yes, describe ________________________________________

6. Has your child had his/her tetanus series or booster? . . . . . . . . q No q Yes If yes, what date? ______________________________________

7. Is your child covered by:

Medi-Cal? . . . . . . . . . . . . . . . . . . . q No q Yes Card number ______________________________

(attach copy of card)

Medical Insurance? . . . . . . . . . . . . q No q Yes Company Name ______________________________________

Policy Number ____________________________

(attach copy of card)

8. If you cannot be located in case of an emergency, who should be called?

Contact 1: Name: ___________________________Relationship _________________Home #: (_____) _______________ Cell #: (_____) ________________

Contact 2: Name: ___________________________Relationship _________________Home #: (_____) _______________ Cell #: (_____) ________________

AUTHORIZATION FOR MEDICAL TREATMENT. If a serious emergency should arise, it might be necessary for a physician to attend to your child before the KEEP staff

could get in touch with you. I hereby authorize KEEP to provide medical and/or surgical care, through the facilities of an appropriate medical facility for the above named

student in any emergency which may occur while he/she is in attendance at KEEP and I further authorize release of such medical information pertaining to the student as

the treating physician or medical facility may require. I hereby give my permission for KEEP to authorize tetanus shot or booster if deemed advisable by a physician at the

appropriate medical facility. This statement must be signed before your child can be accepted at KEEP .

_______________________________________________________________

Parent/Guardian Signature

I hereby give permission for my child to be photographed or videotaped by employees of KEEP and Kern County Superintendent of Schools for educational and promo-

tional use on the KEEP website, social media, television, on brochures or other printed materials.

______________________________________________________________

Parent/Guardian Signature

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Rev. 5/16