Summer Camp

Camper's Name*

First Last

Camper's Date of Birth*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

1st Parent/Guardian Name

First Last

1st Parent/Guardian Cell Phone Number

1st Parent/Guardian Email

2nd Parent/Guardian Name

First Last

2nd Parent/Guardian Cell Phone Number

2nd Parent/Guardian Email

Emergency Contact Name

First Last

Relationship to Camper

Emergency Contact Phone Number

Name(s) of Person(s) OTHER THAN PARENT who are authorized to pick up the camper:

Primary Care Physician's Name

Primary Care Physician's Phone Number

List any known Allergies

List any known Medical Conditions or Limits/Restrictions on Activities

List any Medications and Dosages

Medical Insurance Provider Name

Medical Insurance Number

Will the camper require medications be administered during the program?*

Yes
No

Medical Attention*

I Agree

In the event of serious illness or medical emergency which requires immediate attention, I hereby authorize any treatment as deemed necessary and appropriate by medical personnel

Photo Release*

I Agree

I consent to have my child photographed and/or videotaped, and I also agree to the image and/or video being used by IN-SIGHT for marketing and communications purposes.

Transportation Consent*

I Agree

I give permission for my child to participate in off-site travel with supervision by IN-SIGHT program staff.

Drop Off and Pick Up*

I Agree

Drop off will generally be between 8:15 AM – 8:30 AM each day. Pick up will be at 4:30 PM each day. It is possible that on one or two days that drop-off will be a bit earlier and/or pick-up a bit later. Due to scheduling and staffing issues, campers must be dropped off and picked up at the designated times each day. Families will be provided with a specific daily schedule at least two weeks before camp begins.

T-Shirt Size*

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