Fillable Camp Elachee Emergency, Medical and Pick-Up Authorization Form

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Camp Elachee Emergency, Medical and Pick-Up Authorization Form

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Camp Elachee Emergency, Medical and Pick-Up Authorization Form
Information must be completed in full, signed, and returned to Elachee to finish registration.
Elachee Nature Science Center does not provide camp insurance. Please indicate medical insurance information in all spaces provided. Elachee
reserves the right to ensure the safety of campers and staff and to discontinue camp attendance of individual campers if necessary. Camp Elachee
meets the standards for exemption from licensing through Bright from the Start.
Name of Camper: _______________________________________________ Age: ____________________ ☐Male ☐Female
Height: _____________________ Weight: __________________ Date of Birth (DD/MM/YYYY): _________________________
Child’s School: _____________________________________________________ Entering Grade: ________________________
Home Address: _________________________________ City: ________________________ State: ________ Zip: ___________
Mother/Guardian Name: ________________________________ Home Phone#: ____________ Cell Phone#: ______________
Name of Mother’s Employer: ____________________________________________ Work Phone#: ______________________
Father/Guardian Name: _________________________________ Home Phone#: ____________ Cell Phone#: ______________
Name of Father’s Employer: _____________________________________________ Work Phone#: ______________________
Alternate Emergency Contact Person: __________________________________ Work/Home/Cell#: _____________________
MEDICAL INFORMATION
Insurance Company: ____________________________________ Policy Holder’s Name: _______________________________
Policy Number: ______________________________ Doctor’s Name: _______________________ Phone#: ________________
YES NO
☐ ☐ Does your child have any allergies?
☐ ☐ Has your child ever had an allergic reaction to an insect bite, bee sting, etc? If yes, fill out the Medication
Permission Form with treatment instructions.
☐ ☐ Has your child ever had had a seizure?
☐ ☐ Has your child had any recent operations, illness, or exposure to infectious diseases?
☐ ☐ Is your child taking any medications? If so, please describe below and discuss with your child’s
counselor. Be sure to fill out the Medication Permission Form if the medicine needs to be administered
during camp hours.
Date of last tetanus treatment: ______________________
If you answered “YES” to any of the questions above, please provide full details here:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Our staff members aim to provide the best possible camp experience for your child. Is there anything else you would like us to
know about your child – special needs, fears, etc?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
I affirm and certify that I have answered the previous questions to the best of my knowledge. Initial here: _________
PICK-UP INFORMATION AND PHOTO AUTHORIZATION
Please provide the name(s) of any individual(s) NOT authorized by you to pick up your child: ___________________________
Capturing photos of the children in camp activities is a standard practice. May we have your permission to include your child
in these photos? YES ☐ NO ☐ Please initial here: _________
In the event I cannot be reached in an emergency, I hereby grant permission to the physician selected by Elachee Nature Science Center to
hospitalize, obtain medical records, secure proper treatment for, and order injection, anesthesia, or surgery for my child/ward if necessary. I
understand that all health expenses will be the responsibility of the parent/guardian and hereby grant permission to Elachee to give necessary
health insurance information to the physician selected. My signature below indicates that I have read and understand the procedures outlined
on this health form.
Camp Week(s) your child is registering for: __________________________________
Parent/Guardian Signature: __________________________________________
Date Signed: _______________________
Behavioral Policy and Covenant Not To Sue
Information must be completed in full, signed, and returned to Elachee to finish registration.
BEHAVIORAL POLICY
It is the goal of Elachee Nature Science Center for all participants to have a safe and fun experience. For our camp staff to
maintain safety and an inclusive environment for all children, certain behaviors will not be tolerated. Please discuss with
your child the behavioral expectations, as outlined below, in a way that is appropriate for their age level and behavioral
patterns.
Behaviors that result in an automatic timeout in the Camp Director’s office include, but are not limited to:
• Comments about violent actions towards oneself or others;
• Violent actions towards oneself or other campers such as kicking, hitting, pinching, or
slapping;
• Disrespect of camp staff or another camper’s privacy and/or belongings;
• Purposefully not staying with their camp group;
• Use of profane language;
• Stealing from other campers or the Nature Center
• Any other behaviors as deemed appropriate by camp staff.
Behaviors that accumulate into a timeout in the Camp Director’s office include, but are not limited to:
• Not listening to direction given by counselors or other camp staff;
• Negative comments about or toward other campers;
• Any behavior that is disruptive to the group’s function or activities;
• Any behaviors as deemed appropriate by camp staff.
Office breaks accumulate during the entirety of the summer. Children who receive three timeouts in the Camp Director’s
office cannot return to camp for the duration of the summer. Parents will be notified each time their child receives a break
in the Camp Director’s office. At the time of the third visit with the Camp Director, parents/guardians will be required to
come pick up their child. No money will be refunded for the week during which the third break occurs. A refund will be
processed for all future camp weeks for which the camper is registered, minus a $20 administrative fee per camp week.
COVENANT NOT TO SUE
I, the undersigned, agree to pay, protect, indemnify and hold Elachee Nature Science Center and its staff, volunteers and
directors harmless from and against all liabilities, damages, costs, expenses and claims of any nature whatsoever arising from,
by reason of, or in connection with any injury or death of persons or damage to property arising from, by reason of, or in
connection with our child’s participation in this activity.
I further understand that such activities require all participants to be in good health and without physical limitation. I certify
that my child is in good health and has no physical limitations except as stated on the Camp Elachee Emergency, Medical and
Pick-Up Authorization Form.
The undersigned clearly reserves all rights of action, claims and demands against all other persons not herein named.
By signing this document, you are affirming that you have read, understand and agree to the policies as outlined above.
Note: Document must be witnessed by another adult. Seal of a Notary is not required. No child will be admitted without a completed
Emergency, Medical and Pick-Up Authorization Form, Covenant Not To Sue Form and signed Behavioral Policy.
Parent/Guardian Signature: __________________________________________ Date Signed: _______________________
Witness Signature: _________________________________________________ Date Signed: _______________________
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Camp Elachee Emergency, Medical and Pick-Up Authorization Form

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Completed 10 April 2021

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