Phone: (301) 387-3086 | Fax: (301) 387-3789 | maney.gale@garrettcollege.edu

Garrett College Camps


Emergency Contact and Medical Information for a Child

Child's Legal Name

Nickname


Parent's/Guardian's Name


Work Phone

2nd Work Phone


Cell Phone

2nd Cell Phone


Email

Camper's Birthday


Street

City


State

Zip Code


Alternative Emergency Contacts


Emergency Contact


Home Phone

Cell Phone


Street


City

State

Zip


Are you a CARC Member?

Yes

No



T-shirt Size

Payment Arrangements


Registering for the Upcoming Camp(s):



Medical Information:


Hospital/Clinic Preference

Insurance Holder Full Name


Insurance Company

Insurance Policy


I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian cannot be reached in the case of an emergency.


Release Information


Travel & Trip Release


I give permission for my child participate in camp field trips, including travel to and from the destination. In consideration of the advantages of participation in field trips, the undersigned agrees that the Garrett College, its agents and employees, and the driver and/or owner of the vehicle used for the field trip shall be released and exempt from any liability for damages for bodily injuries or property damages that may occur during the trip, except to the extent of insurance liability as provided by law.

Photo Release


I give permission and consent for photographs to be taken during camp session activities. I further give permission and consent that any such photographs may be published and used by Garrett College and its agents, to illustrate and promote the camp experience or Garrett College.

Sunscreen Policy


Garrett College Camps are aware of how damaging UV rays from the sun can be to your child’s skin. During the summer months, or when necessary, campers will apply sunscreen approximately thirty minutes before going outside, and in 1 hour intervals during on and off-campus outside activities. Garrett College requests that parents supply one bottle of sunscreen prior to expiration date with their child’s first and last name labeled on the bottle. Parents will be informed when a new bottle is needed.

If your child has an allergy to sunscreen a doctor’s note must be provided and will be attached to this policy and kept in your child’s folder. Garrett College will take other precautions to protect your child from overexposure to the sun, such as: wearing a hat and playing in shaded areas.

I agree to the above terms stated in this policy.


Timely Pick-up Policy


Late pick-ups will be recorded. Parents should make every effort to pick-up their children no later than the advertised camp end time (varies by camp, please consult your camp’s specific hours). Please consider weather and traffic conditions when making your pick-up arrangements. If a child is not picked up by the advertised camp end time, the following policy will be followed:

1. Late pick-up: Late pick-up recorded
2. Late Pick-ups: Recorded, $1.00/minute late fee assessed
3. Or more late pick-ups: Recorded, suspension or termination of your child’s enrollment in the program

Events will happen that are out of our control, but please consider having a back-up plan or two in place for those times. We are more than happy to take a list of persons authorized to pick-up your child(ren) in the event you cannot.

I have read and do understand this policy. The following list of people are authorized to pick up my child when I am unable to do so. I understand that it is my responsibility to make arrangements with these authorized parties when needed.

Authorized Persons Able to Pick-Up Camper:

Full Name

Relationship to Camper

Contact Phone Number


Full Name

Relationship to Camper

Contact Phone Number


The following information is required for a camper to be admitted to day camp:

Camper Immunization Information

All campers must be current on all immunizations, see www.EDCP.org (Immunization).

1. Provide date (month and year) of camper's last tetanus (or DTP) shot:

2. Is the camper currently enrolled in a Maryland school, public or private?



3. Is the camper exempt from any immunization on medical or religious grounds?



Additional Health Information


All information required, please be thorough.


Ever been hospitalized?
 
 

Ever had surgery?
 
 

Have recurring/chronic illness?
 
 

Had a recent infectious disease?
 
 

Had a recent injury? ?
 
 

Had asthma / wheezing / shortness of breath?
 
 

Passed out/had chest pain during exercise?
 
 

Had seizures?
 
 

Had fainting or dizziness?
 
 

Had headaches?
 
 

Have problems with diarrhea/constipation?
 
 

Have a history of bedwetting?
 
 

Have problems with falling asleep/sleepwalking?
 
 

Wear glasses, contacts, or protective eyewear?
 
 

Ever had back/joint problems?
 
 

Have any skin problems?
 
 

Have diabetes?
 
 

Had "mono" in the past 12 months?
 
 

Traveled outside the country in the past 9 months?
 
 

If female have problems with periods/menstruation?
 
 

Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD)?
 
 

Ever been treated for emotional or behavioral difficulties or an eating disorder?
 
 

During the past 12 months seen a professional to address mental/emotional health concerns?
 
 

Had a significant life event that continues to affect the participant's life (abuse, death of a loved one, divorce, adoption, foster care, new sibling, survived a disaster)?
 
 

Physician

Phone


Dentist

Phone


Orthondontist

Phone


ADDITIONAL INFORMATION NOT COVERED PREVIOUSLY:

Provide any additional information you feel that we should be aware of to ensure that your child’s camp experience is positive:

This health history is correct and accurately reflects the health status of the individual to whom it pertains. The person described has permission to participate in all camp activities except as noted above and/or by an examining licensed medical professional. I give permission to the licensed medical professional selected by the camp to order x-rays, routine tests, and treatment related to the health of the individual for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the licensed medical professional to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for the individual. I understand the information on this form will be shared on a 'need to know' basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of the described individual's health record from providers who treat them and these providers may talk with the program's staff about the described individual's health status in emergency situations.

Parent/Guardian Signature

Date