Name: Nature Day Camp Registration &amp; Health Form - COMPLETE FORM - REQUIRED
SKU: 11182
Availability: InStock

Description

Nature Day Camp Registration & Health Form

- Step 1 of 8

Do you authorize Fenner to use pictures of your camper in printed materials, videos, social media, posts, displays, etc.? *

Camper Name *

First

Last

Parent/Guardian #1 Name *

First

Last

Parent/Guardian #2 Name *

First

Last

Fenner Conservancy Member *

Camper Gender *

Male
Female
Other
I prefer not to answer

Camper Date of Birth *

Camper' Current Age *

Camper's Grade Completed in Spring 2023 *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Primary Phone Type *

Secondary Phone

Secondary Phone Type

Email *

How Did You Hear About Us?

Returning Camper
Referred by a Friend
Social Media
Online Advertising
Print Media

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? *

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 #

Allergies & Immunizations

Is your camper up to date on immunizations? If no, please contact Fenner at (517) 483-4224 for further information. *

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.

Photo Release Form - Minors

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.

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

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

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

Providing your Electronic Signature confirms that you understand and agree with conditions listed above in the Parent/Guardian Authorization Form. Your Electronic Signature stands in place of your written signature

Date *

Nature Day Camp Registration & Health Form – COMPLETE FORM – REQUIRED

Description

Camper Information Form

Camper Health Form

Allergies & Immunizations

Photo Release Form - Minors

APPROVED Camper Pick-Up List

NOT APPROVED Camper Pick-Up List

Parent/Guardian Authorization Form