Summer Camp Forms Step 1 of 8 12% Name & Contact InformationParent/Guardian Name(Required) First Last Camper's Name(Required) First Last Email(Required) Phone(Required) Publish Photography & Video PermissionThroughout the summer, we will take photographs and videos of children attending camp. By agreeing to this waiver, you will allow camp staff to take photos and videos for internal and promotional use. Please indicate whether or not you authorize the use of your child’s image. Photo & Video Use(Required) I agree I do not agree May we Use Your Child's Name with the Photos or Videos? I agree I do not agree Pickup AuthorizationFrom time to time you may find it necessary for someone else to pick up your child from camp. In order to ensure the safety of all children in our care, we are unable to release your child to any adult other than you the parent/guardian, unless you have given us prior written permission. Please list below any adults that have your permission to pick up your child. If they are permitted to pick up at any time, please state ‘any time’.Authorized Person #1 First Last Relationship to ChildTypical Pick Up Days/TimesAuthorized Person #2 First Last Relationship to ChildTypical Pick Up Days/TimesAuthorized Person #3 First Last Relationship to ChildTypical Pick Up Days/Times Emergency Medical PermissionsPermission(Required)I, grant permission for my child, to be treated for illness or injury as needed at camp. I give permission to transport my child to the nearest emergency room. I Grant Permission I Do Not Grant Permission Over-the Counter Skin ProductsI grant Connect Plus Therapy staff permission to use the following products with my child and understand the possible, known adverse reactions (if any) that could happen.Products(Required) Sunscreen Hand Sanitizer Bug Spray First-aid Ointment None If you are sending in an OTC product with your child, it must be in the original container and, if provided by a parent, labeled with the child’s name. Sunscreen must have a minimum sunburn protection factor (SPF) of 15. Field Trip PermissionThroughout the summer, campers may have the opportunity to participate in activities that may involve travel to off-site locations and events. Transportation options vary. Please complete the following steps to help us prepare for addressing the transportation needs of your child. Permissions(Required) I give my child permission to ride with the camp on a private bus, or comparable transportation, under the supervision of administrators, faculty, or staff. I give my child permission to ride in a vehicle driven by administrators, faculty, or staff. I do not give permission. Child's AgeCar Seat or BoosterYes, one is needed.No, one is not needed. Food AllergiesPlease list all food allergies, if any.Reactions to Ingestion, Touch, or Smell?Does your child need to eat in a peanut-free area?(Required)Please SelectYesNoAre you providing an Epi-Pen to be kept in the camp office?(Required)Please SelectYesNoIs there a history of anaphylactic shock?(Required)Please SelectYesNoPlease describe possible allergic reactions.Please provide any emergency medical instructions you'd like us to follow. SignatureTyping your full name below will act as your signature and confirm that all of the information you have is accurate.Full Name(Required)Today's Date(Required) MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Step 1 of 8 12% Name & Contact InformationParent/Guardian Name(Required) First Last Camper's Name(Required) First Last Email(Required) Phone(Required) Publish Photography & Video PermissionThroughout the summer, we will take photographs and videos of children attending camp. By agreeing to this waiver, you will allow camp staff to take photos and videos for internal and promotional use. Please indicate whether or not you authorize the use of your child’s image. Photo & Video Use(Required) I agree I do not agree May we Use Your Child's Name with the Photos or Videos? I agree I do not agree Pickup AuthorizationFrom time to time you may find it necessary for someone else to pick up your child from camp. In order to ensure the safety of all children in our care, we are unable to release your child to any adult other than you the parent/guardian, unless you have given us prior written permission. Please list below any adults that have your permission to pick up your child. If they are permitted to pick up at any time, please state ‘any time’.Authorized Person #1 First Last Relationship to ChildTypical Pick Up Days/TimesAuthorized Person #2 First Last Relationship to ChildTypical Pick Up Days/TimesAuthorized Person #3 First Last Relationship to ChildTypical Pick Up Days/Times Emergency Medical PermissionsPermission(Required)I, grant permission for my child, to be treated for illness or injury as needed at camp. I give permission to transport my child to the nearest emergency room. I Grant Permission I Do Not Grant Permission Over-the Counter Skin ProductsI grant Connect Plus Therapy staff permission to use the following products with my child and understand the possible, known adverse reactions (if any) that could happen.Products(Required) Sunscreen Hand Sanitizer Bug Spray First-aid Ointment None If you are sending in an OTC product with your child, it must be in the original container and, if provided by a parent, labeled with the child’s name. Sunscreen must have a minimum sunburn protection factor (SPF) of 15. Field Trip PermissionThroughout the summer, campers may have the opportunity to participate in activities that may involve travel to off-site locations and events. Transportation options vary. Please complete the following steps to help us prepare for addressing the transportation needs of your child. Permissions(Required) I give my child permission to ride with the camp on a private bus, or comparable transportation, under the supervision of administrators, faculty, or staff. I give my child permission to ride in a vehicle driven by administrators, faculty, or staff. I do not give permission. Child's AgeCar Seat or BoosterYes, one is needed.No, one is not needed. Food AllergiesPlease list all food allergies, if any.Reactions to Ingestion, Touch, or Smell?Does your child need to eat in a peanut-free area?(Required)Please SelectYesNoAre you providing an Epi-Pen to be kept in the camp office?(Required)Please SelectYesNoIs there a history of anaphylactic shock?(Required)Please SelectYesNoPlease describe possible allergic reactions.Please provide any emergency medical instructions you'd like us to follow. SignatureTyping your full name below will act as your signature and confirm that all of the information you have is accurate.Full Name(Required)Today's Date(Required) MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
