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Kalamazoo Nature Center
Creating relationships & experiences that welcome and inspire people to discover, enjoy, value, and care for nature.
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MENU
MENU
Visit
Plan Your Visit
Calendar
Trails
About KNC
Equity
Exhibits & Arts
Resources & Things to Do
Programs
Calendar
Events
Camp
DeLano Farms
Terry Todd Speaker Series
Education
School & Group Programs
Fair Food Matters
Heronwood
Nature's Way Preschool
Conservation
Community Science
KNC Land Management
Research
Ecological Services
Rentals
Rent a Space
Outdoor Venues
Indoor Venues
Rental Packages
Birthday Parties
Meetings and Retreats
Join the Team
Employment
Volunteer
Community Science
Support
Donate Now
Ways to Give
Sponsorships
Tributes & Planned Giving
Camper Information Form
CAMPER INFORMATION FORM
(TO BE COMPLETED BY PARENT/GUARDIAN) PLEASE FILL OUT ONE FORM FOR EACH CHILD ATTENDING KNC CAMP. **THE CONTENTS OF THIS FORM WILL REMAIN CONFIDENTIAL**
Camper Name
*
Birth Date
*
Grade Entering in Fall
*
Gender Identity
*
Select
Female
Male
Non-Binary
Other
Gender Identity
Pronouns
For Summer Camp Only
*
Outdoor Leaders
Adventure Skills
Adventure Treks
Wild Child Day
Wild Child Camp-Out
Explorers Day
Junior Naturalists AM
Junior Naturalists PM
Junior Farmers
Neurodiversity
NWP Alumni
Sessions
*
1
2
3
4
5
6
7
8
(select all that apply)
Parent/Guardian 1
*
Please include parent/guardian within Authorized Pickup Information section below
Relationship
*
Phone
*
Primary Email
*
Primary Contact?
*
Yes
No
Camper Home Address
*
Camper Home Address
Camper Home Address
Camper Home Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Parent/Guardian 2/Emergency Contact 1
*
Please note, we require 3 different emergency contact for campers
Relationship
*
Phone
*
Email
*
Primary Contact?
*
Yes
No
Home Address (if different)
*
*Emergency Contact 2 (other than parents/guardian)
*
Please note, we require 3 different emergency contact for campers
Relationship
*
Phone
*
Email
*
AUTHORIZED PICKUP INFORMATION
*Anyone not listed will not be allowed to pick up your child, this includes parents/guardians/emergency contacts if they are not listed below. A photo ID is required for pick up.*
Authorized Pickup 1
*
Phone
Email
Authorized Pickup 2
*
Phone
Email
Authorized Pickup 3
*
Phone
Email
GENERAL CAMPER INFORMATION
Sibling(s) Attending Camp
Camp Buddy Request (both campers MUST request)
Has the camper attended camp before?
*
Yes
No
If yes, please describe their experience
Please use this space for any important details we may need to provide an excellent experience for your camper
How well does your camper swim?
*
Does not swim
Beginner
Intermediate
Advanced
What are your camper’s interests, hobbies, and talents?
What do you hope your camper to gain from their camp experience?
Please describe any recent major life events/achievements. Examples include new siblings, a recent death in the family, divorce, a change in your job status, moving, academic or athletic achievements
How would you describe your camper’s personality?
PHOTO RELEASE
The Kalamazoo Nature Center (KNC) may take photographs, video, or other digital media from this event to promote KNC. I understand that the images may be used in any form for print publications, online publications, presentations, websites, and social networking sites. I also understand that all photograph, video, or other digital media are the property of KNC and no royalty, fee or other compensation shall become payable to me. KNC will not sell these images or videos. Does KNC have permission to take and use photographs of the camper as outlined above?
*
Yes
No
MEDICAL INFORMATION
Is your camper up to date on Immunizations? (Please upload a copy of the camper’s vaccination records below)*
*
Yes
No
Attach vaccination records*
Drop a file here or click to upload
Choose File
Maximum file size: 134.22MB
Allergies
*
No Known Allergies
Food
Medicine
Environmental
Please Describe
*
Dietary Restrictions
*
No Restictions
Vegan
Vegetarian
Lactose Intolerance
Gluten Intolerance
Other (please describe)
Other (please describe)
Restrictions:
*
I have reviewed the program of activities and feel my camper can participate WITHOUT restrictions.
I have reviewed the program of activities and feel my camper can participate WITH restrictions. Please describe below
Please Describe
*
MEDICAL INSURANCE INFORMATION
This camper is covered by family medical insurance:
*
Yes
No
Insurance Company
*
Policy Number
*
Subscriber
*
Insurance Company Phone
*
PRIMARY CARE PROVIDER INFORMATION
PCP Name
*
Phone
*
Office Address
*
Office Address
Office Address
Office Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
MEDICATIONS
Medication name
Date Started
Reason
Time Administered
Dose
Will this medication be administered at camp?
Yes
No
Medication name
Date Started
Reason
Time Administered
Dose
Will this medication be administered at camp?
Yes
No
Medication name
Date Started
Reason
Time Administered
Dose
Will this medication be administered at camp?
Yes
No
Medication name
Date Started
Reason
Time Administered
Dose
Will this medication be administered at camp?
Yes
No
Medication name
Date Started
Reason
Time Administered
Dose
Will this medication be administered at camp?
Yes
No
Medication name
Date Started
Reason
Time Administered
Dose
Will this medication be administered at camp?
Yes
No
Medication name
Date Started
Reason
Time Administered
Dose
Will this medication be administered at camp?
Yes
No
Medication name
Date Started
Reason
Time Administered
Dose
Will this medication be administered at camp?
Yes
No
Medication administration notes
The following non-prescription (OTC) medications are used on an as-needed basis to manage illness or injury. Please select any OTC medications that may NOT be administered to your camper:
Ibuprofen
Calamine Lotion
Cortisone Cream
Bismuth (stomach relief)
Pseudoephedrine (allergy relief)
Tylenol
Baking Soda
Diphenhydramine (allergy relief)
HAS/DOES THE CAMPER:
1. Ever been hospitalized?
*
Yes
No
11. Have a history of bedwetting?
*
Yes
No
2. Ever had surgery?
*
Yes
No
12. Have recurrent diarrhea/constipation?
*
Yes
No
3. Have recurrent/chronic illnesses?
*
Yes
No
13. Have back/joint problems?
*
Yes
No
4. Had a recent infectious illness?
*
Yes
No
14. Traveled outside the country in the last 12 months?
*
Yes
No
5. Have problems falling asleep/sleepwalking?
*
Yes
No
15. Had fainting/dizziness?
*
Yes
No
6. Had asthma/wheezing/shortness of breath?
*
Yes
No
16. Had headaches?
*
Yes
No
7. Have problems with menstruation?
*
Yes
No
17. Had seizures?
*
Yes
No
8. Had mononucleosis in the last 12 months
*
Yes
No
18. Have diabetes?
*
Yes
No
9. Passed out/had chest pain during exercise
*
Yes
No
19. Had a recent injury?
*
Yes
No
10. Wear glasses, contacts, or protective eyewear?
*
Yes
No
20. Have skin problems?
*
Yes
No
Please explain “yes” answers
*
If answered yes in questions 1-20, please explain. If no to all, please write N/A
1. Has the camper ever been treated for Attention Deficit/Hyperactivity Disorder?
*
Yes
No
2. Has the camper ever been treated for emotional or behavioral difficulties?
*
Yes
No
3. Has the camper ever been treated for an eating disorder?
*
Yes
No
4. Has the camper seen a professional for mental or emotional health concerns in the past 12 months?
*
Yes
No
5. Has the camper had a significant life event that continues to affect the camper’s mental/emotional health?
*
Yes
No
Please explain “yes” answers
*
If answered yes in questions 1-5, please explain. If no to all, please write N/A
GENERAL RELEASE OF LIABILITY AND AUTHORIZATION FOR TREATMENT
Camper Name
*
I hereby agree that this health history is correct to the best of my knowledge and the camper herein described has permission to engage in all camp activities except as noted. This completed form may be photocopied for trips out-of-camp. In consideration for being allowed to participate in the Kalamazoo Nature Center’s programs, I agree to assume the risk of such activities and programs and I further agree to hold harmless the Kalamazoo Nature Center and its staff members conducting the activities from any and all claims, suits, losses, or related causes of action for damages including, but not limited to, such claims that may result from injury or death, accident or otherwise, during or arising in any way from the activities. I grant permission for me or my child to participate in all planned camp activities including hiking and out-of-camp trips by van or bus, understanding that competent leadership is provided. The Kalamazoo Nature Center is not responsible for lost, stolen, or damaged personal articles. I also authorize the Kalamazoo Nature Center and its assignees to use any photograph or likeness of me or my child for print or electronic promotional purposes. I hereby give permission to the medical personnel selected by the camp staff to order X-rays, routine tests, treatment, and necessary transportation for me or my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp staff to secure and administer treatment, including hospitalization, for my child as named above. I acknowledge that this General Release of Liability and Authorization for Treatment of the Kalamazoo Nature Center is legally binding on me personally and on my heirs, personal representatives, successors, and assignees.
*
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