Camp Forms

7

CAMPER INFORMATION FORMThis side to be completed by PARENT or GUARDIAN

CAMP GORDON CLARK

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 # ( )

Mother or Guardian Name: Day Phone # ( )

Pager/Cell Phone # ( )

EMERGENCY CONTACT INFORMATION: (by MA state law — phone # must be other than home)

1. Name: Day Phone # ( )


PERMISSION SLIP: (Signature Required)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)

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.




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:

Any additional health information:

Do you carry Family Medical Insurance? Yes No

Insurance Carrier: Policy #:

Important — this box must be completed for attendance:(Signature Required)

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 selectedby the Camp Nurse to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as namedabove. I also give permission for routine medical care for my child by the camp. This form may be photocopied for use off camp property.

Parent/Guardian Signature: Date:

Please Fill OutCompletely!

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CAMPER

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How did you hear about Camp Gordon Clark?Newspaper Website Facebook Friend Other

Physician to fill out side 2

8

HEALTH FORMThis side to be completed by a LICENSED HEALTH CARE PROVIDER

CAMP GORDON CLARK

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 1 POLIO 1

MMR 2 IPV/OPV 2

3

DTP/DTaP 1 4

DT/Td 2 5

3

4

HEP B 1 OTHER 1

2 2

3 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 Ear Infection(s)/tube Diabetes Convulsions Insect Stings/Allergy/Sensitivity Penicillin AllergyAsthma ADD/ADHDOther

B. Recommendations and restrictions while at camp:

C. Any additional health information:

2. HEALTH CARE PROVIDER: Date:

Physician’s Signature:

Printed Name:

Address:

Phone #: ( )

Parent/Guardian tocomplete other side

Parent/Guardian to fill out side 1

Street

City State Zip

Please carefully clip out the attached form

CAM

PER

NAM

E:

(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 $14/Day (Check below if attending full week) (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 □Th □F

□Week 3 July 9 ~ July 13 □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



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:________________________

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