CAMP GORDON CLARK
CAMPER INFORMATION FORM This side to be completed by PARENT or GUARDIAN Camper’s Last Name:
First Name:
Address:
City/State/Zip:
Male
Female
Birth Date:
/
/
Age:
Email:
Grade entering September 2012:
Home # (
Father or Guardian Name:
Day Phone # ( Pager/Cell Phone # (
)
Day Phone # ( Pager/Cell Phone # (
)
How did you hear about Camp Gordon Clark? Newspaper Website Facebook Friend
)
CAMPER NAME:
Mother or Guardian Name:
Please Fill Out Completely!
)
)
Other
EMERGENCY CONTACT INFORMATION: (by MA state law — phone # must be other than home) 1. Name: 2. Name:
Day Phone # ( Day Phone # (
) )
PERMISSION SLIP: (Signature Required)
GN SI
HE RE !
I give permission to use any pictures, images or likeness taken of my child during participation at camp by the YMCA in connection with any publication, program or any and all media, including the South Shore YMCA website, and YMCA authorized social media and marketing materials. I understand the camp fees do not include health and accident insurance, and I will be responsible for any and all charges incurred for prompt medical treatment. Parent/Guardian Signature:
PICK UP AUTHORIZATION: (All campers must be picked up and signed out by an authorized adult — Signature Required)
GN SI
The following individuals have authorization to pick-up my child. The Parent/Guardian listed above does not need to be included. Please inform anyone that you list that a photo ID will be required upon pick-up of your child. 1. Name: Day Phone # ( ) 2. Name: Day Phone # ( ) 3. Name: Day Phone # ( )
HE RE !
Parent/Guardian Signature:
HEALTH HISTORY: Doctor preference:
Phone # (
)
Please list any allergies to bee stings, food, medications, etc.: Please list any medications (including inhalers) that the camper is on: Please indicate if your child is under the care of a physician for any of the following condition(s): Seizure Disorder Ear Infection(s)/tube Diabetes Convulsions Insect Stings/Allergy/Sensitivity Penicillin Allergy Asthma ADD/ADHD Other Any recommendations and restrictions while at camp: Do you carry Family Medical Insurance? Insurance Carrier:
Yes
No Policy #:
Important — this box must be completed for attendance: (Signature Required)
GN SI
Please carefully clip out the attached form
Any additional health information:
EMERGENCY AUTHORIZATION: I hereby give permission to the medical personnel selected by the Camp Nurse to order x-rays, routine tests, and treatment for my child. In the event that I cannot be reached in an emergency, I also hereby permit the physician selected by the Camp Nurse to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named above. I also give permission for routine medical care for my child by the camp. This form may be photocopied for use off camp property.
HE RE Parent/Guardian Signature: !
Date:
Physician to fill out side 2
7
Parent/Guardian to complete other side
CAMP GORDON CLARK
HEALTH FORM This side to be completed by a LICENSED HEALTH CARE PROVIDER
Camper MUST have a Health Form turned in yearly to attend camp. Camper’s Name:
Date of Birth:
/
/
1. IMMUNIZATIONS: (Mandatory Law in Massachusetts) Required:
MMR MMR
1 2
DTP/DTaP DT/Td
1 2 3 4
HEP B
1 2 3
POLIO IPV/OPV
1 2 3 4 5
OTHER
1 2 3
VARICELLA (vaccine or disease)
2. HEALTH EXAMINATION: A. I have examined the camper applicant named on the reverse side within the past 12 months Date of last physical: In my opinion the condition of the camper (please circle one) DOES / DOES NOT preclude the participation in an active camp program. The applicant is under the care of a physician for the following condition(s): Seizure Disorder Convulsions Asthma Other
Ear Infection(s)/tube Insect Stings/Allergy/Sensitivity ADD/ADHD
Diabetes Penicillin Allergy
CAMPER NAME:
B. Recommendations and restrictions while at camp: C. Any additional health information:
2. HEALTH CARE PROVIDER:
Date:
Physician’s Signature:
Address:
Street City
Phone #: (
8
)
Parent/Guardian to fill out side 1
State
Zip
Please carefully clip out the attached form
Printed Name:
(You MUST complete a separate form for each camper) Camper’sName:______________________________________________________ Camper’s Address: ___________________________________________________ Date of Birth: _____________________ Grade: ___________ Parent/Guardian’s Name: _____________________________________________ Home Phone #: __________________ Work Phone #: _________________ Cell Phone #: ____________________ E-Mail: ________________________ $64.00/Week
SESSION
(Check below if attending full week)
$14/Day (Check below if paying by day)
□Week 0
June 18 ~ June 22
□M □T □W □Th □F
□Week 1
June 25 ~ June 29
□M □T □W □Th □F
□Week 2
July 2 ~ July 6
□M □T
□Week 3
July 9 ~ July 13
□M □T □W □Th □F
□Week 4
July 16 ~ July 20
□M □T □W □Th □F
□Week 5
July 23 ~ July 27
□M □T □W □Th □F
□Week 6
July 30 ~ August 3
□M □T □W □Th □F
□Week 7
August 6 ~ August 10
□M □T □W □Th □F
□Week 8
August 13 ~ August 17
□M □T □W □Th □F
□Week 9
August 20 ~ August 24
□M □T □W □Th □F
□Th □F
Payment Type: Credit Card Check (payable to: South Shore YMCA) AMOUNT: $_______ Visa Master Card Discover American Express Credit Card Number:____________________ Expiration Date: ________________ Name On Card: _______________________ Security Code: _________________ *A non-refundable payment is due in full at time of registration* _______________________________________ Parent/Guardian Signature
____________ Date
CAMP GORDON CLARK PICK UP AUTHORIZATION FORM 2012 CAMPER’S LAST NAME_________ FIRST NAME:__________ Camper’s Group ___________________ DOB:___________
Pick up Authorization add on: All campers must be picked up and signed out by an authorized adult. The following individuals have authorization to pick-up my child. Please inform anyone that you list that a photo ID will be required upon pick-up of your child. 1. Name ________________ Day Phone # ___________ 2. Name ________________ Day Phone # ___________ 3. Name ________________ Day Phone # ___________ Parent/Guardian Signature:________________________