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**
*For Summer Camp Only*
Sessions (select all that apply)
Please include parent/guardian within Authorized Pickup Information section below
Primary Contact?
Camper Home Address
Camper Home Address
City
State/Province
Zip/Postal
Please note, we require 3 different emergency contact for campers
Primary Contact?
Please note, we require 3 different emergency contact for campers

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.*

GENERAL CAMPER INFORMATION

Has the camper attended camp before?
How well does your camper swim?

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?

MEDICAL INFORMATION

Is your camper up to date on Immunizations? (Please upload a copy of the camper’s vaccination records below)*

Maximum file size: 134.22MB

Allergies
Dietary Restrictions
Restrictions:

MEDICAL INSURANCE INFORMATION

This camper is covered by family medical insurance:

PRIMARY CARE PROVIDER INFORMATION

Office Address
Office Address
City
State/Province
Zip/Postal

MEDICATIONS

Will this medication be administered at camp?
Will this medication be administered at camp?
Will this medication be administered at camp?
Will this medication be administered at camp?
Will this medication be administered at camp?
Will this medication be administered at camp?
Will this medication be administered at camp?
Will this medication be administered at camp?
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:

HAS/DOES THE CAMPER:

1. Ever been hospitalized?
11. Have a history of bedwetting?
2. Ever had surgery?
12. Have recurrent diarrhea/constipation?
3. Have recurrent/chronic illnesses?
13. Have back/joint problems?
4. Had a recent infectious illness?
14. Traveled outside the country in the last 12 months?
5. Have problems falling asleep/sleepwalking?
15. Had fainting/dizziness?
6. Had asthma/wheezing/shortness of breath?
16. Had headaches?
7. Have problems with menstruation?
17. Had seizures?
8. Had mononucleosis in the last 12 months
18. Have diabetes?
9. Passed out/had chest pain during exercise
19. Had a recent injury?
10. Wear glasses, contacts, or protective eyewear?
20. Have skin problems?
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?
2. Has the camper ever been treated for emotional or behavioral difficulties?
3. Has the camper ever been treated for an eating disorder?
4. Has the camper seen a professional for mental or emotional health concerns in the past 12 months?
5. Has the camper had a significant life event that continues to affect the camper’s mental/emotional health?
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