Nature Avengers Registration AUTHORIZATION TO TRANSPORT THE CAMPER HEALTH INFORMATION
Our primary concern is the health, safety, and well-being of your child. For this reason, please provide the following information. All medical information is confidential.
Name of Child's Physician
Physician's Phone Number Is your child covered by medical insurance? * Is your child up-to-date with all immunizations required for school? *
Please list any allergies or intolerance to food, medication, etc. (ex. penicillin, bee stings/bites, peanuts, dairy, latex, etc.)
If an allergic reaction occurs, please list the steps necessary to relieve the reaction (EPI PIN, Benedryl) Does your child currently receive services at school for any physical, emotional or behavioral needs? *
Please explain. * Does your child wear glasses, contacts, or protective eye-wear? *
Please explain. * Is your child currently taking any medication? *
Please explain. * Will your child require medication during camp hours? *
Please explain. * Does your child have any activities limited by a physician? *
Please explain. * Are there any emotional or behavioral conditions which might affect camp experience (ADD, ADHD)? *
Please explain. * Has there been any previous hospitalization? *
Please explain. * Does your child have current or previous psychiatric counseling? *
Please explain. * Have there been operations or serious injuries? *
Please explain. * Are there any disabilities, chronic or recurring conditions such as asthma, fainting, or nose bleeds? *
Please explain. * Are there any dietary restrictions? *
Please explain. * Are there any other important health considerations? *
Please explain. * Does your child have diabetes or related illness? *
Please explain. * Does your child experience seizures? *
Please explain. * Does your child use insulin? *
Please explain. * MORE ABOUT YOUR CHILD
What would you like us to help your camper accomplish during his/her time at Camp Kum-Ba-Yah?
Please provide any specific information you feel would help us better understand your camper. Photo/Video Release
Camp Kum-Ba-Yah hereby requests permission to use photographs and/or video footage of the camper(s) named on this application for the purpose of program promotion. By checking "yes" and signing this application, the parent/legal guardian releases Camp Kum-Ba-Yah from all legal claims and/or fees while using the photographs and/or video footage for promoting its program.
Please choose one option * EMERGENCY AUTHORIZATION
I, as parent or guardian of a camper, give permission to the medical or dental personnel selected by the Camp Director to order x-rays, routine tests and treatment for the camper. In the event I cannot be secured in an emergency, I hereby give permission to the physician or dentist selected by the Camp Director to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for the camper. In the event of a serious allergic reaction or condition requiring immediate attention on site, I authorize the Camp Director or personnel selected by the Camp Director to give the appropriate medication which can include but not be limited to, epi pen or benadryl. I further acknowledge I will be responsible for the payment of all charges related to the medical or dental services for the camper beyond the limits of the camp’s accident and/or liability insurance policy. This form may be photocopied for use outside of camp.If my child becomes ill during camp hours, I agree to pick up my child as soon as possible. Otherwise, the above “Emergency Authorization” applies.I further agree to report to Camp Kum-Ba-Yah within 24 hours if any member of the camper’s immediate household has developed any communicable disease as defined by the State Board of Health, except for life threatening diseases which must be reported immediately.
We need your consent before accepting your child into the program. * PARENT/GUARDIAN AGREEMENT and AUTHORIZATION
I, as parent or guardian of a camper, understand Camp Kum-Ba-Yah takes reasonable precautions to insure the program and activities at Camp Kum-Ba-Yah are conducted by qualified personnel in a safe and responsible manner. However, I further understand these activities involve certain risks which include, but are not limited to, ropes course, water sports, food preparation over a campfire, and hiking. I, the undersigned, parent/guardian of a camper, individually and on behalf of the camper, recognize these risks and agree to assume these risks by attending or allowing the camper to attend Camp Kum-Ba-Yah and participate in these programs.I, as parent/guardian, individually and on behalf of the camper, hereby release, discharge, and agree to save-harmless and indemnify Camp Kum-Ba-Yah, its Director, Program Directors, Members of the Board, staff and volunteers from all liability for damage, injury, illness, or death to the camper or his/her property relating to or deriving from his/her presence at Camp Kum-Ba-Yah or participation in or travel to or from Camp Kum-Ba-Yah activities.I give permission for my child to be transported by Camp Kum-Ba-Yah to and from approved program activities and/or in case of emergency.I have read and understand the contents of this application, including the Emergency Authorization, the Refund and Cancellation Policy, the Payment Policy, and the Parent Agreement.
We need your agreement and authorization before accepting your child into the program. * POLICIES AGREEMENT CANCELLATION Cancellations will not receive a refund. Camp Kum-Ba-Yah reserves the right to cancel camp 72-hours prior to the start date/time due to low registration numbers. In this case, participants will receive a full refund. WHAT TO BRING • Campers should bring their own lunch and a water bottle labeled with child’s name for each day of camp. Please do not send food that needs to be heated. In consideration of children with allergies, please do not send any food containing nuts or peanut butter. • We strongly encourage all campers to bring sunscreen, wear closed toed shoes and dress for the weather. Activities will be outdoors unless presented with extreme weather conditions. • We recommend campers bring a change of clothes to camp each day. These should be contained in a grocery or zip-top bag with camper’s name written on it. • Campers are encouraged to bring a small backpack, no large packs please, to contain their personal items. Late Pick Up Camp Kum-Ba-Yah reserves the right to assess a late pick-up fee of $1.00 per minute beyond camp hours at the discretion of the camp facilitator. A pick-up will be considered "late" at 15 minutes past camp end time. AFTERCARE Aftercare is not available for Nature Avengers Camp Please read the Policies Agreement above and indicate your agreement here. * Submit