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#: _____________________
Insurance Company: ____________________________________ Policy Holder’s Name: _______________________________
Policy Number: ______________________________ Doctor’s Name: _______________________ Phone#: ________________
☐ ☐ 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: _______________________