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/ Summer Camp Registration & Health Form – COMPLETE FORM – REQUIRED
Summer Camp Registration & Health Form – COMPLETE FORM – REQUIRED
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Summer Camp Registration & Health Form - COMPLETE FORM - REQUIRED quantity
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Description
Description
Summer Camp Registration & Health Form
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 8
Camper Name
*
First
Last
Parent/Guardian #1 Name
*
First
Last
Parent/Guardian #2 Name
*
First
Last
Fenner Summer Camps - 2022
*
Bugs & Slugs - June 13-17
Hook, Line, & Sinker - June 20-24
Wilderness Skills - June 27-July 1
Eco Art - July 11-15
Gross Nature - July 18-22
NSI: Nature Scene Investigation - July 25-29
Urban Agriculture - August 1-5
Scales & Tails - August 8-12
Fenner Summer Camp Groups - 2022
*
K-1st (Group 1)
K-1st (Group 2)
2nd-3rd
3rd-4th
4th-5th
5th-6th
Please select the group indicating the grade your camper is completing in Spring 2022.
Fenner Summer Camps Aftercare - 4:00-5:30pm
AFTERCARE - Bugs & Slugs - June 13-17
AFTERCARE - Hook, Line, & Sinker - June 20-24
AFTERCARE - Wilderness Skills - June 27-July 1
AFTERCARE - Eco Art - July 11-15
AFTERCARE - Gross Nature - July 18-22
AFTERCARE - NSI: Nature Scene Investigation - July 25-29
AFTERCARE - Urban Agriculture - August 1-5
AFTERCARE - Scales & Tails - August 8-12
Fenner Conservancy Member
*
Yes
No
Camper Gender
*
Male
Female
Other
I prefer not to answer
Camper Date of Birth
*
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Camper' Current Age
*
Camper's Grade Completed in Spring 2022
*
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
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
Zip Code
Primary Phone
*
Primary Phone Type
*
Home
Work
Cell
Secondary Phone
Secondary Phone Type
Home
Work
Cell
Email
*
How Did You Hear About Us?
Returning Camper
Referred by a Friend
Social Media
Online Advertising
Print Media
Next
Camper Information Form
Has your camper attended a summer camp in the past? If so, when and where?
*
Is your camper attending camp with a friend/sibling? If so, what are their names?
*
Does your camper have any fears or concerns about attending camp? If so, what are they?
*
Does your camper have any challenges that you would like to share with their counselor, such as physical limitations, special health, or behavioral considerations?
*
Next
Camper Health Form
Place of Work - Parent/Guardian #1
*
Work Phone - Parent/Guardian #1
*
Place of Work - Parent/Guardian #2
Work Phone - Parent/Guardian #2
Emergency Contact (Primary)
*
First
Last
Emergency Contact (Primary) Phone
*
Emergency Contact (Secondary)
First
Last
Emergency Contact (Secondary) Phone
Health Insurance Carrier/Plan Name
Policy Holders Name
First
Last
Health Insurance Policy #
Next
Allergies & Immunizations
Is your camper up to date on immunizations? If no, please contact Fenner at (517) 483-4224 for further information.
*
Yes
No
Does your camper have any allergies? If yes, please list allergy type and reaction below.
*
Does your camper have any dietary restrictions? If yes, please list them below.
*
Is your camper currently taking any medications? If yes, please list medication name, dosage, frequency, and reason for treatment below.
*
Any medications accompanying your camper to Fenner camps must be in original packaging clearly identifying the prescribing physician, medication name, dosage, and frequency of administration.
Please indicate which over the counter medications you authorize Fenner staff to administer to your camper if necessary.
Asprin
Acetaminophen
Cough Drops
Saline Eye Drops
Antacid
Aloe Gel
Caladryl Lotion
Hydrocortisone Cream
Antibiotic Ointment
Has your camper... (check all that apply)
recently had an injury, illness, or infectious disease
had a chronic/reoccurring illness or condition
experienced frequent headaches
ever been knocked unconscious or had a head injury
ever had frequent ear infections
been diagnosed with a heart murmur
ever had skin problems
ever had back problems
ever had a history of bed wetting
ever had, or currently has asthma
ever been hospitalized
ever had surgery
ever had seizures
ever worn, or currently wears glasses, contacts, or protective eyewear
If you checked any of the boxes above, please explain.
Next
Photo Release Form - Minors
Do you authorize Fenner to use pictures of your camper in printed materials, videos, social media, posts, displays, etc.?
*
Yes
No
If no, please upload a picture of your child for identification purposes. This picture is for OFFICE USE ONLY.
Click or drag a file to this area to upload.
Next
APPROVED Camper Pick-Up List
Please list the names of anyone APPROVED to pick-up your camper. (Please include your own name)
*
First
Last
Approved
First
Last
Approved
First
Last
Approved
First
Last
Approved
First
Last
Approved
First
Last
Approved
First
Last
Next
NOT APPROVED Camper Pick-Up List
Please list the names of anyone NOT APPROVED to pick-up your camper.
First
Last
NOT Approved
First
Last
NOT Approved
First
Last
NOT Approved
First
Last
NOT Approved
First
Last
NOT Approved
First
Last
NOT Approved
First
Last
Next
Parent/Guardian Authorization Form
I give permission for my child to attend the Fenner Nature Center, Nature Day Camp in Lansing, MI. I have read and agree with all of the information provided within Fenner’s Summer Camp Registration & Health Form. To the best of my knowledge, the information that I have provided within Fenner’s Summer Camp Registration & Health Form is correct and complete. The camper listed on this form has permission to engage in all camp activities except as noted. I give permission for the camp First Aid personnel to provide routine health care, administer prescribed medications, and administer first aid treatment on site. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I give my permission to the camp to arrange necessary related transportation for my child if I cannot be reached in the event of an emergency. I give permission to the physician or the camp First Aid personnel to hospitalize, secure proper and/or routine treatment, and to order injection, anesthesia, x rays, or surgery in the event that I cannot be reached in an emergency. This completed form may be photocopied for trips outside/offsite of camp.
Name (Electronic Signature)
*
First
Last
By typing in your name you confirm the above stands in place of your signature
Date
*
Submit