KIDSbury Summer Camp Registration 2022 Camper's First Name(*) Please enter the camper's first name Camper's Last Name(*) Please enter the camper's last name Birthdate(*) Invalid Input PARENT or GUARDIAN Parent/Guardian(*) Invalid Input Street Address(*) Invalid Input City(*) Invalid Input State(*) Invalid Input ZIP Code(*) Invalid Input Phone Number(*) Invalid Input Alternate Phone Invalid Input Email Address(*) Please let us know your email address. EMERGENCY CONTACT (if parent cannot be reached) Emergency Contact(*) Invalid Input Emergency Phone(*) Invalid Input PAYMENT Membership Type(*) Member Non-member Invalid Input *non-refundable deposit of $50 is required to secure your week(s) Payment Type(*) House Charge (members) Check Credit Card Invalid Input CAMP KIDSbury Camp(*) Week 1 - June 20 to June 24Week 2 - June 27 to July 1Week 3 - July 5 to July 8 (4 days - pro-rate week)Week 4 - July 11 to July 15Week 5 - July 18 to July 22Week 6 - July 25 to July 29Week 7 - August 1 to August 5Week 8 - August 8 to August 12Week 9 - August 15 to August 19Week 10 - August 22 to August 26 Invalid Input * For Week 10 - August 22 to August 26 - call for availability before submitting this form. * INSURANCE INFORMATION Is Camper covered by Medical/Hospital Insurance?(*) YesNo Invalid Input Insurance Provider Invalid Input Policy # Invalid Input ALLERGIES (List ALL known - include reaction and management of reaction. If none, please write "None") Medication Allergies(*) Please list allergies. If none, please write "none." Food Allergies(*) Please list allergies. If none, please write "none." Other Allergies (insect sting, asthma, etc.)(*) Please list allergies. If none, please write "none." MEDICATIONS (List ALL medications taken routinely) Does Camper take medications routinely(*) Yes No Invalid Input Medication 1 Invalid Input Dosage Invalid Input Time(s) Invalid Input Reason for taking Invalid Input Medication 2 Invalid Input Dosage Invalid Input Time(s) Invalid Input Reason for taking Invalid Input Please provide a description of any current physical, mental, or psychological conditions requiring medication, treatment or special restrictions, accommodations or considerations while at camp: Invalid Input List any past medical treatment (i.e. recent injuries, illness, surgery etc.) If none, please write "None":(*) Please list past medical treatment. If not applicable, please write "none" or "N/A." Please describe any camp activities from which the camper should be exempted for health reasons. If none, please write "none." Please list medically exempted activities. If not applicable, please write "none" or "N/A." PARENT AUTHORIZATIONS 1. I give permission to the camp health supervisor to share information relevant to my child's health condition with appropriate camp personnel when needed to meet my child's health and safety needs. 2. I give the camp health supervisor permission to exchange information with my child's Primary Care Physician for the purpose of referral, diagnosis, and treatment. 3. I give the camp health supervisor permission to administer Tylenol, Advil, Motrin, ibuprofen, cough drops, and/or over-the-counter medications as deemed necessary. Manufacturer's dosage guidelines shall be used. 4. I give the camp health supervisor permission to delegate medication administration to non-licensed personnel after proper instruction on the dose, route, frequency and reason for administration of the medications(s) when deemed safe and appropriate. Staff is instructed to activate EMS in emergency situations. 5. In the event reasonable attempts to contact me by phone have been unsuccessful, I hereby give my consent for the administration of any treatment deemed necessary by a licensed physician or dentist and for the transfer of my child to any hospital reasonably accessible. 6. I agree to the release of any records necessary for insurance purposes. 7. The camper herein described has permission to go on off campus trips (if applicable). 8. I give permission for the contact, insurance, and parent/guardian sections of any forms to be photocopied for off campus trips (if applicable). 9. Risk Warning Statement: The Kingsbury Camp asks campers to participate in a variety of activities throughout the season. Many of these activities carry some risk of injury. The camp makes every effort to provide: -Safe transportation -Safe equipment and facilities -Competent instruction and supervision It is important that the camp has a record of your acknowledgement of these risks, and we ask you to sign and return this form. It is a statement agreeing that you understand that there are risks involved for campers involved in camp-sponsored activities. 10. I understand that my child will not be allowed to attend Kingsbury Camp until I have provided health records fully in compliance with state and local regulations. I understand and agree that it is the responsibility of the parent/guardian to provide the completed health information. I have read and agree to the above Parent Authorization(*) Yes Invalid Input Parent/Guardian signature(*) Invalid Input Please provide a copy of the most recent MD physical done within the last 12 months including day/month/year of ALL basic immunizations and all booster doses. Validation Invalid Input