City of Santa Clarita :: Camp Clarita
2011-2012 Camp Clarita Health History Form
PARTICIPANT INFORMATION
Camper's First Name:
*
Camper's Last Name:
*
Birth Date:
*
MM/DD/YYYY
Gender:
*
Female
Male
Parent/guardian email:
*
Address:
City:
Zipcode:
Home Phone:
Father/Guardian:
*
Work Phone:
*
Cell Phone:
*
Mother/Guardian:
*
Work Phone:
*
Cell Phone:
*
* Please provide full name for the Parent/Guardian
PROGRAM INFORMATION
Camp Program:
*
---Select---
Wee Folks Camp
Little Folks Camp
Ranger Camp
Explorer Camp
Voyager Camp
Winter Adventures
Camp Location:
*
---Select---
Activities Center
Canyon Country Park
Newhall Park
North Oaks Park
Santa Clarita Park
Valencia Glen Park
Valencia Meadows Park
EMERGENCY CONTACT AND PERSONS AUTHROIZED TO PICK UP MY CHILD
(Other than parents)
Name:
*
Relationship:
*
Phone:
*
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
HEALTH INFORMATION
The information you provide here will be held in the strictest confidence. It will be kept on file in our binder or carried by the camp director on field trips.
Name of Physician
Address
Phone Number
Allergies:
*
Yes
No
If yes for
Allergies
, please list the allergies and describe the severity of the reaction (medication, seasonal, food, etc.):
Medical, Physical, or Emotional Conditions (including Disabilities):
Above information allows staff to provide your child with the best camp experience.
Does your child require reasonable accommodations through our inclusion program:
*
Yes
No
Will your child need to take medication while at camp?:
*
Yes
No
Any medication dispensed to your child must be brought to camp in its original prescription container and a
separate form
must be completed.
INSURANCE INFORMATION
Carrier/Plan Name
Group Policy Number
Name of insured
Address
Phone
Relationship to Camper
PERMISSION TO PARTICIPATE / CAMP POLICIES AND PROCEDURES
Electronic Parent/Guardian Signature (required)
Yes
— I voluntarily agree to allow my child to participate in the above named program, or any extension thereof.
I hereby waive, release, and hold harmless from any liability or claims for damages for personal injury including accidental death, as well as from claims for property damage which may arise in connection with the above named activity, against the Supervisors, City of Santa Clarita, and its elected and appointed officials, agents, and employees. As a parent/guardian, I hereby consent to treatment of my minor child for any and all medical procedures deemed necessary as a result of accident or injury. I further agree to pay any and all costs incurred as a result of said treatment. I hereby give permission to the City of Santa Clarita to use my child(ren)’s photographs as they see fit for promotional purposes. I understand the photographs belong to the City and I will not receive payment of any kind.
An original signature is also required, therefore, you will be asked to sign this form on your child’s first day of camp.
