Middle School Winter Camp 2025 Form Template - PDF Templates

Monday, November 18, 2024

Item - Middle School Winter Camp 2025 Form Template Image-1 0

2025 M.S. Winter Camp Registration

February 7-8 | Join us for Kimball Camp in Reading, MI

PARTICIPANT INFORMATION:

Participant Name

Rebecca VanDosen

Participant Phone Number

(269) 689-5678

Participant Home Address

asdfjkl

Sturgis, Mi, 49091

Birth Date

Thursday, August 14, 1997

Gender (for housing considerations only)

Female

Participant School

Centreville

Grade

List anyone specific you would like to room with

PARENT/GUARDIAN INFORMATION:

Parent/Guardian Name

Rod Chupp

Address (if different than student address)

Phone Number

(123) 456-7890

E-mail

dad@yahoo.com

SECONDARY EMERGENCY CONTACT:

Secondary Emergency Contact

Mom Chupp

Phone Number

(123) 456-7808

AUTHORIZED PICKUP PERSON(S):

If different than the names listed above.

Authorized Pickup Person(s)

Authorized Pickup Person(s) Phone Number

MEDICAL INFORMATION

**If you do not have a physician or medical insurance, please put N/A in the spaces provided.**

Physician Name

Dr. Health Worker

Physician Phone Number

(123) 432-3833

Address

123

Sturgis, mi, 49091

Has the participant had a physical within the last 24 months?

Yes

Medical Insurance Company

CHM

Policy Number

N/A

Allergies - check those that apply and specify nature of allergic reaction:

None

Gluten

Non-Prescription Medications:

The following non-prescription medications may be used on an AS NEEDED BASIS to manage illness and injury. Please indicate below which medications the participant may NOT receive. These non-prescription medications will be administered by YFC staff according to manufacturer's labeled dosages unless a written statement (prescription) from participant's health-care provider authorizes a different dosage.

Check the medications a camper should NOT have:

Loperamide HCI (i.e. Imodium AD)

Loratidine (i.e. Claritin)

Medication Administration Instructions:

"If medicine is present during YFC activities, that medicine must have written instructions present with it during the activity from a doctor, parent, or legal guardian." Any medication, prescription or over-the-counter, brought to an YFC activity must have written medical instructions and dosage information from a physician, parent or legal guardian. All medications must be in the original container where issued.

List the name of medications, time of day fo

r administering, things to consider for admi

nistering:

Tylenol as needed - 2 pills

2 Tums morning & night

Medical Concerns

Don't let have a lot of sugar or caffeine

LIABILITY RELEASES

These releases MUST be completed by the parent/guardian of the participant, unless the participant is 18 years of age or older.

YFC Consent and Release of Liability: I represent that I am the participant named (if 18 or over) or the legal parent/guardian of the child named, who is under 18 years of age. In consideration for allowing my child to participate in this activity and ongoing YFC activities, I hereby consent to the foregoing on behalf of my child and agree that this release shall be binding upon me, my child, our heirs, legal representatives and assigns.*