Spring Break Camp Health Form

Student Information

Full Name *

Date of Birth *

Grade *

Will your child be attending the full week of camp? *

Yes
No

Guardians Information

Guardians's Name *

Email *

Phone *

Relationship to the Student *

Emergency Contacts

Persons listed must be reachable during camp hours. List contacts in order of who to contact first.

Full Name *

Phone *

Relationship to the Child *

Full Name *

Phone *

Relationship to the Child *

Medical Information & Special Consideration

Fill out any that apply to your child. With Awarness of your child's special needs, staff may be able to modify activities and Techniques for inclusiveness prior to the start of camp.

Medical or behavioral conditions *

No Specific medical or behavioral Conditions
Food allergies
Non-food allergies
Any physical, emotional or bahavioral conditions, including cognative, LD, ADD, ADHD, or autism requiring medication, treatment, special restrictions or condiferations while at camp.

My child is currently taking medication. *

Yes
No

Health Insurance/ Physician

Insurance Company

Policy/Group Number

Participant ID Number

Physician's Name

Office Phone

Date of last Tetanus shot

Immunizations: Are the child's immunizations current?

Yes
No

Please list an major medical treatment within the last year:

Permission To Secure Treatment

Camp staff are available who are trained in First Aid, CPR, AED, EpiPen, and asthma inhaler assistance. They will take whatever emergency medical measures are deemed necessary for the protection and safety of the camper within their training.

In the event of any emergency, I authorize the Sci-Tech Discovery Center to secure from any licensed hospital, physician, and/or medical personnel any treatment deemed necessary for me or my minor child/ward’s immediate care and agree that I will be responsible for payment of any and all medical services rendered. I understand that this authorization includes transporting my child by ambulance if necessary to the nearest medical treatment facility if I am unable to be reached first. I will not hold the Sci-Tech Discovery Center responsible for personal injury, death, or loss of property.

Signature *

Clear Signature

Photo Release

Photo Release *

Yes, I give permission for my child's picture to be used in marketing and social media for Sci-tech Discovery Center.
No, I do NOT give permission for my child's picture to be used in marketing and social media for Sci-tech Discovery Center.

Sick Policy

Student with a fever must stay home.

Students with mild sysmptoms (sneezing, runny nose, slight cough) may attend camp, but must wear a mask.

Sick Policy *

I agree

Food Policy

Students must bring their own lunch, snack & water bottle.

All food items must be nut free.

Food Policy *

I agree

Signature of Parent *

Clear Signature

Printed Name *

Date of Signature *