CAMPER INFORMATION
Child's Name
Gender
Age
Birthdate
Grade Level This Fall
Home Address
City
State
Zip
Home Phone
Is The Child A Returning Camper?
Mother's Name
Father's Name
Home Address
Home
Address
Home Phone
Home Phone
Work Phone
Work Phone
If Parent's Are Seperated, Who Has Custody Of The Child?
Other Emergency Contacts: Persons Authorized To Pick Up Child
(Other Than Parent). It Is Your Responsibility To Transport Your Child
To And From FISHCAMP. Dates And Times Are Provided With Your Confirmation
Letter.
Name
Phone
Name
Phone
INFORMATION FOR EMERGENCY ROOM
Physician's Name
Address
Phone #
In An Emergency, Please Notify
At The Following Number
Do You Have Health Insurance?
Policy Name and Number
Please List All Medications And Reasons Why They Are Taken
Can Your Camper Swim?
Allergic Reactions (Please Include Food Allergies)
Last Tetanus Shot
Accidents: In case of an accident, an instructor will evaluate the
child to determine any possible broken bones, neck, head, or internal
injuries, or there potential trauma. If there are any potential injuries,
we will call 911 for an ambulance. In case of minor scrapes and bruises,
the proper health care will be provided. Should injury require attention
that cannot be provided by the camp. The child will be transported
by the EMS or parent. All attempts to notify a parent will be made
prior to transportation and to advise them of the injury and arranged
transportation.
Appointment of Agent: (Authorization for Emergency Care)
I Hereby Appoint Camp Director and/or Camp Staff As My Agent and Representative
For The Purpose Of Authorizing And Consenting To Medical and/or Hospital
Care And Treatment, Under The Supervision Of Licensed Physician Or
Surgeon, Of
(Name Of Child), For Any Illness That May
Occur While Such Person Is In Care Or Custody Of The Agent, Between
The Dates Of
. If I Am Not Immediately Available
To Give Such Consent.
Parent's Signature
Date
Please Include Any Additional Notes About Your Child That We Should
Know About So That We Can Make Your Child's Stay Most Enjoyable. Thanks!
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