Student Emergency Contact Information

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STUDENT EMERGENCY CONTACT INFORMATION
ALL INFORMATION REQUIRED -- Please complete this form and return PRIOR to first day of camp.
In the event of an emergency, Camp staff will make every effort to contact the child’s parent/guardian(s). If no contact can be made,
the following people will be contacted in the order listed. All camps end at 3:00 each day. Students must be picked up by 3:15pm. If
you wish to enroll your child in the Extended Day Program, please complete form included in handbook. Students are only released to
the following people. Identification may be requested.
Child’s Name____________________________________________________________ Age___________________
Camp Name__________________________________________ Camp Dates_______________________________
EMERGENCY CONTACT #1 - PARENT or LEGAL GUARDIAN
Name__________________________________________________________ Relationship _______________________
Daytime Phone #______________________________ Alternate Phone #_____________________________
EMERGENCY CONTACT #2 - OTHER THAN PARENT ABOVE
Name________________________________________________________ Relationship ________________________
Daytime Phone #___________________________ Alternate Phone #__________________________
EMERGENCY CONTACT #3 - OTHER THAN PARENT ABOVE
Name________________________________________________________ Relationship ________________________
Daytime Phone #___________________________ Alternate Phone #__________________________
CHILD’S PHYSICIAN:_____________________________________________ Phone:________________________
HEALTH INFORMATION
please carefully review our medication policies before completing this section
1) Are there any health problems including physical, psychiatric, or behavioral problems which we need to be aware of?
__No __Yes (
Answering “YES” to this question may require COMPLETION of additional forms found in the Medication Policies & Forms Addendum.)
If YES, please explain:_____________________________________________________________________________________
______________________________________________________________________________________________________________
2) Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child’s
camp experience is positive?
__No __Yes (
Answering “YES” to this question may require COMPLETION of additional forms found in the Medication Policies & Forms Addendum.)
If YES, please explain:__________________________________________________________________
_____________________________________________________________________________________________________________
IMMUNIZATION INFORMATION
For campers who reside within the United States, a US territory, or the District of Columbia:
1) state/territory in which child resides: _____________________
2) is this child exempt from any immunizations? __No
__Yes, list them:____________________________________
- OR -
For campers who reside outside the United States, a US territory, or the District of Columbia:
1) country in which child resides:_______________________________
2) attach Department of DHMH-896 (record of vaccination of immunity)
OTHER
SUNSCREEN/BUGSPRAY-- Students should apply sunscreen and bug spray PRIOR to arrival at camp. In the event additional applications
are needed, my child has permission to self-apply additional sunscreen and/or bug spray? __Y __N
SNACKS –Permission to eat a popsicle? __Y __N (ingredient list posted at Sign-In table) Permission to eat watermelon? __Y __N
CCOMMUNITY GARDEN – my child has permission to taste tomatoes and/or lettuce from the (organic) Community Garden? __Y __N
Parent/Guardian Signature:_________________________________________________ Date:____________

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