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Kids Camp Registration

KIDSbury Summer Camp Registration 2019

Camper First Name(*)
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Camper Last Name(*)
Please let us know your name.

Birthdate(*)
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PARENT or GUARDIAN
Parent/Guardian(*)
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Street Address(*)
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City(*)
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State(*)
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ZIP Code(*)
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Phone Number(*)
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Alternate Phone
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Email Address(*)
Please let us know your email address.

EMERGENCY CONTACT (if parent cannot be reached)
Emergency Contact(*)
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Emergency Phone(*)
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PAYMENT
Membership Type(*)
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Payment Type(*)
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CAMP
KIDSbury Camp(*)

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INSURANCE INFORMATION
Is Camper covered by Medical/Hospital Insurance?(*)
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Insurance Provider
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Policy #
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ALLERGIES (List ALL known - include reaction and management of reaction)
Medication Allergies
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Food Allergies
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Other Allergies (insect sting, asthma, etc.)
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MEDICATIONS (List ALL medications taken routinely)
Does Camper take medications routinely(*)
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Medication 1
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Dosage
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Time(s)
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Reason for taking
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Medication 2
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Dosage
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Time(s)
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Reason for taking
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Please provide a description of any current physical, mental, or psychological conditions requiring medication, treatment or special restrictions, accommodations or considerations while at camp:
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List any past medical treatment (i.e. recent injuries, illness, surgery etc.):
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Please describe any camp activities from which the camper should be exempted for health reasons
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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(*)
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Parent/Guardian signature(*)
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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
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