Eppley Recreation Center 4128 Valley Drive College Park, MD CAMPER PROFILE FORM due by May 31, 2017

Transcription

1 CAMPER PROFILE FORM due by May 31, 2017 Camper Name (last, first):_, (preferred name, if any): Camper Address (street): (City, State, Zip Code):,, School attending in 2017:_ Age at start of camp: years months Grade entering fall 2017: Height: _ Weight: _ Date of Birth: Please check session(s) for which your child is already registered for: Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Camper T-shirt (circle one): youth: S M L OR adult: S M Friend Request (not guaranteed): Parent Information Parent/Guardian name & relationship:, Emergency Contact information: (phone) / ( ) Parent/Guardian name & relationship:, Emergency Contact information: (phone) _ / ( ) _ Medical Insurance Information Carrier: Phone Number: ID/POLICY Number

2 CAMPER PROFILE FORM due by May 31, 2017 Camper Name: Health: 1. Does your child have any allergies (medicine, food, animal, insect, etc.) Yes No If yes, please list 2. Is your child currently taking prescribed medication for a chronic or ongoing illness or condition, such as Asthma, Attention Deficit Hyperactivity Disorder, Diabetes, etc? Yes No If yes, please elaborate. 3. Will you child continue to take this medication during his/her time at camp? Yes No If yes, please complete a Day Camp Participant Medication Form. If no, please explain, 4. Does your child have any dietary restrictions or concerns? 5. Please share with us any special concerns you might have which you feel we and/or our counselors should know about (ex. IEP, 504, counseling, major life changes. Please attach copy of IEP or 504) If your child will need to take medications during the day, please complete the medication form found on line and submit along with all required forms by May 27, In signing below, you agree to submit these forms on time. In case of emergency or illness, every effort will be made to contact the parents or guardians. In the event that contact cannot be made, I hereby grant permission for physicians, dentists, or other licensed health care providers and their designees employed by The state of Maryland to administer outpatient medical, surgical, or dental services as appropriate, or necessary antigens or other injections, to perform emergency procedures as necessary, or to refer to duly licensed medical personal when indicated. Parent/Guardian Signature: Date:_

3 DAY CAMP PARTICIPANT MEDICATION FORM - Due by Friday, May 31, 2017 This form must be completed for participants who require any medication or medical device during program hours. Each medication (i.e. prescription and over-the-counter) to be taken, or medical device (inhaler/epi-pen) used during program hours requires completion of the physician s authorization section below. Camp staff is not authorized to administer medication. Staff may remind individuals and distribute the medication to the participant. Staff will accept up to a two-week supply of medication in its original pharmaceutical container that will be verified (counted) with parent/guardian when initially left at camp. Parent/guardians are solely responsible for ensuring an adequate quantity of medication is provided to staff with the physician s written instructions for distribution. All medication or medical devices must be stored in a locked storage box provided by the staff at the site which will accompany participants on the various trips. If a participant requires immediate access to an Epi-pen or asthma inhaler, the waiver below must be completed and signed by a parent/guardian. This will allow the participant to carry the device. Participant Name Birth Date Participant Address_ Physician Authorization This section must be completed and signed by physician for every participant who requires any type of medication or medical device during program hours. Name of Medication(s) Reason for Medication(s) Medication Dose Special Directions for Medication When is Medication to be Taken Possible Medication Side Effects Physician s Signature Printed Name Physician s Address_ Physician s Phone Number Date Waiver Allowing Participant to Carry Epi-Pen/Asthma Inhaler This section must be completed, and signed by a parent/guardian for every participant who requires that an Epi-Pen and/or asthma inhaler be kept on his/her person while participating in an activity. Due to the potential necessity for immediate medication distribution imposed by my child s life threatening condition, I _, hereby request that be allowed to keep the appropriate prescribed device on his/her person while participating in all camp activities. The prescribed device is: Epi/Pen or _ Asthma Inhaler. I understand that to qualify for this exemption, this child must be capable of safely storing the necessary Epi-pen or asthma inhaler on his/her person (fanny pack or pocket) and using the device appropriately. Medication/Release Authorization I hereby represent and warrant that if the participant is a minor, I am his/her parent/guardian and authorized to provide the release, authorization and waiver contained herein and agree to the camp policies as stated above. I agree to release the staff and its agents from any and all liability arising as a result of this waiver. Print parent/guardian name Date Signature_

4 MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE IMMUNIZATION CERTIFICATE CHILD'S NAME LAST FIRST MI SEX: MALE FEMALE BIRTHDATE /_/ COUNTY _ SCHOOL GRADE PARENT NAME PHONE NO. _ OR GUARDIAN ADDRESS CITY ZIP RECORD OF IMMUNIZATIONS (See Notes On Other Side) Vaccines Type Dose # DTP-DTaP-DT Polio Hib Hep B PCV Rotavirus MCV HPV Dose # Hep A MMR Varicella History of Varicella Disease 1 1 Mo/Yr Td 4 5 Tdap FLU Other To the best of my knowledge, the vaccines listed above were administered as indicated. 1. _ Signature Title Date (Medical provider, local health department official, school official, or child care provider only) 2. _ Signature Title Date 3. _ Signature Title Date Clinic / Office Name Office Address/ Phone Number Lines 2 and 3 are for certification of vaccines given after the initial signature. COMPLETE THE APPROPRIATE SECTION BELOW IF THE CHILD IS EXEMPT FROM VACCINATION ON MEDICAL OR RELIGIOUS GROUNDS. ANY VACCINATION(S) THAT HAVE BEEN RECEIVED SHOULD BE ENTERED ABOVE. MEDICAL CONTRAINDICATION: Please check the appropriate box to describe the medical contraindication. This is a: Permanent condition OR Temporary condition until // Date The above child has a valid medical contraindication to being vaccinated at this time. Please indicate which vaccine(s) and the reason for the contraindication, Signed: _ Medical Provider / LHD Official Date RELIGIOUS OBJECTION: I am the parent/guardian of the child identified above. Because of my bona fide religious beliefs and practices, I object to any vaccine(s) being given to my child. This exemption does not apply during an emergency or epidemic of disease. Signed: _ Date: DHMH Form 896 Rev. 2/14 Center for Immunization

5 PARENTAL RELEASE AND PARENTAL INFORMED CONSENT FORM - Due by May 31, 2017 In consideration of the University of Maryland s acceptance of my minor child for participation in the University Recreation and Wellness TERP Quest Day Camp program, including the use of University Recreation and Wellness facilities and equipment, I, on behalf of said minor child and myself, our heirs, personal representative(s) and assigns hereby represent and agree as follows: 1. I acknowledge that I have been provided with information regarding the TERP Quest Day Camp, including its activities, policies, and procedures. I understand that the camp program includes various recreational and adventure activities, sports, and swimming, as well as the University Recreation and Wellness rock climbing wall and ropes challenge course. NOTE: The University Recreation and Wellness rock climbing wall and ropes challenge course consist of a number of activity elements that range from 2 feet to over 50 feet off the ground, including a 50 high ropes alpine tower, a 55 climbing wall, and a giant swing. Participation in climbing wall and challenge course activities is limited to children who are big enough to fit into the required safety equipment (harness and helmet). Alternative adventure activities will be provided for children who do not participate in the climbing wall and challenge course. 2. I understand and agree that my child must abide by all rules, regulations, expectations and standards of conduct applicable to participation in the TERP Quest Day Camp Program. I further understand and agree that University Recreation and Wellness reserves the right to suspend, limit or terminate my child s participation in any activity, or in the TERP Quest Day Camp program if, in the sole discretion of University Recreation and Wellness staff, my child s conduct or actions do not conform to said rules, regulations, expectations, and standards of conduct or are otherwise dangerous, destructive, or disruptive. 3. I understand that the TERP Quest Day Camp program requires a minimum level of fitness and skill for safe participation. I also understand that University Recreation and Wellness advises that participants in the TERP Quest Day Camp have a physical examination to determine their fitness for participation. I further understand that the University of Maryland does NOT provide medical, health or other insurance for participants in the TERP Quest Day Camp program. 4. Should my child require first aid or emergency treatment as a result of illness or injury associated with participation in the TERP Quest Day Camp program, I consent to such first aid or treatment. 5. I fully recognize and understand that there are risks and hazards, both minor and serious, associated with participation in the TERP Quest Day Camp program and/or use of University Recreation and Wellness or other university facilities and equipment, including, but not limited to: cuts, scrapes, bruises, broken bones, muscle strains, pulls or tears, other bodily injuries, spinal injuries, heat prostration, brain damage, blindness, deafness, drowning, heart attacks, temporary or permanent disabilities, paralysis and, even, death. 6. Knowing the dangers, hazards and risks associated with participation in the TERP Quest Day Camp program, and with sufficient knowledge of my child s physical condition(s) and limitations, if any, I voluntarily assume all responsibility and risk of loss, damage, illness and/or injury to person or property which my child may, in any way sustain in connection with his/her participation in the TERP Quest Day Camp program. 7. To the fullest extent permitted by law, I hereby release and forever discharge, and agree not to sue and to indemnify and hold harmless, the State of Maryland, the University of Maryland, University Recreation and Wellness, and their officers, agents, employees and volunteers from and against any and all liabilities, claims, demands and causes of action of any kind on account of any loss, damage, illness or injury to person or property in any way arising out of or relating to my child s participation in the TERP Quest Day Camp program and/or use of University Recreation and Wellness or other university equipment or facilities, whether due to the negligence, default or other action or inaction of any person or entity. I CERTIFY THAT I AM 18 YEARS OF AGE OR OLDER AND THAT I HAVE READ AND FULLY UNDERSTAND THIS RELEASE AND INFORMED CONSENT FORM, AND I SIGN IT VOLUNTARILY WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE. Signature of Parent/Guardian Having Care Date Child s Name Printed Name of Parent/Guardian and Custody of Participating Child

6 MIXED MEDIA CONSENT, WAIVER, AND RELEASE - due by May 31, 2017 I CONSENT AND GIVE PERMISSION to the University of Maryland to photograph my child in connection with University Recreation and Wellness sponsored TERP Quest Summer Day Camp activities. I understand that any such photographs, and all rights associated with them, will belong solely and exclusively to the University, which shall have the absolute right to copyright, duplicate, reproduce, alter, display, distribute, and/or publish them in any manner, for any purpose, and in any form including, but not limited to, print, electronic, video, and/or Internet. I voluntarily waive any and all rights with respect to any such photographs, including compensation, copyright, and privacy rights and any right to inspect or approve such photographs and/or copy, print or other materials that may be used in connection with them. I hereby release and discharge, and agree to hold harmless, the University, its officers, agents and employees, and all persons acting under its permission or authority, from any claims and liability in connection with such photographs and/or their use. I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS CONSENT, WAIVER, AND RELEASE FORM, AND I SIGN IT FREELY AND VOLUNTARILY. In signing below, I CONSENT OR GIVE PERMISSION to the University of Maryland to photograph my child in connection with University Recreation and Wellness TERP Quest Summer Day Camp Activities. Printed Child Name (First, Last) Printed Parent Name (First, Last) Parental Signature Date OR In signing below, I DO NOT CONSENT OR GIVE PERMISSION to the University of Maryland to photograph my child in connection with University Recreation and Wellness TERP Quest Summer Day Camp Activities. I acknowledge that my child will be separated from his/her activity group during periods in which campers may be photographed or filmed. Printed Child Name (First, Last) Printed Parent Name (First, Last) Parental Signature Date Note: TERP Quest does not publish participant names in conjunction with any media produced

7 Eppley Recreation Center 4128 Valley Drive, College Park, MD AUTHORIZED PICK-UP/ EMERGENCY CONTACT FORM due by May 31, 2017 Emergency Contact / Camper Pick-up: Parents/guardians listed on the first page of this document DO NOT need to be listed below. If you need to have anyone other than a parent/guardian pick-up your child, a completed and signed Pick-up/Release Authorization Form must be submitted to TERP quest PRIOR TO the camper s departure from camp. Sorry, but for everyone s safety WE CANNOT accept phone messages or notes provided by the pick-up person at the pick-up point. For your child s protection we cannot make any exceptions to this policy. Please, only one camper per form. Please complete additional forms for additional campers. All names listed on the Camper Profile Form and the Authorized Pick-Up/Emergency Contact Form below should also be added to your Online Account as Authorized Pick-up persons. Failure to update your records may result in a delay in the release of your camper to you. Authorized Person(s) for Pick Up: As legal, custodial parent/guardian of (camper s full name), I (parent/guardian name), _, give the following individuals permission to pick-up my child: PICK-UP AUTHORIZED PERSON EMERGENCY CONTACT? 1. _ YES NO 2. _ YES NO 3. _ YES NO 4. _ YES NO 5. _ YES NO I understand that neither TERP Quest nor any of its representatives can be held responsible for my child once they are under the supervision of the individual listed above. For the safety of the camper, TERP Quest representatives may ask the individual listed above to verify their identity by showing an official picture ID (drivers license, ID card, current passport, etc.) prior to releasing the camper. Legal Custodial Parent/Guardian Signature: Date: Un-Authorized Person for Pick Up: Please notify Camp in writing if there is someone who should not be allowed to pick-up you child. If a family member is not permitted to pick-up you camper, a certified copy of the court order must be forwarded to the attention of TERP Quest Summer Day Camp attention. The following are legally restricted from picking up my child. A copy of a court order is enclosed: Name: Relationship: Legal Custodial Parent/Guardian Signature: Date:

8 SUNSCREEN AUTHORIZATION FORM Dear TERP Quest Parents/Guardians, The Maryland Department of Health and Mental Hygiene has adopted the below policy regarding the use of sunscreen at youth camps. In order to operate a camp in the state of Maryland, we must abide by the policy as outlined below. Please read the following regarding the use and application of sunscreen at TERP Quest Summer Day Camp. The below authorization form is to be completed and submitted along with the sunscreen labeled for your camper (one form and one bottle per camper) at morning dropoff the first day of camp and at the start of each subsequent week, if brand of sunscreen changes, or a new bottle is supplied at any time. Thank you. TERP Quest Summer Day Camp Sunscreen Policy 1. TERP Quest Summer Day Camp must obtain written permission from a parent/guardian regarding use and application of sunscreen (see form below) 2. Sunscreen must be clearly labeled with the individual child s name and must be submitted to TERP Quest camp staff at check in along with the Authorization Form the Monday morning of each session 3. Campers should, in most instances, apply sunscreen on their own. If assistance is needed, it will be provided by camp staff ONLY if authorized (see below). 4. Campers need to have sunscreen applied to them by the parent/guardian before arriving at camp TERP QUEST SUMMER DAY CAMP SUNSCREEN AUTHORIZATION FORM (2017) Camper Name (printed): Brand of sunscreen: SPF: Expiration Date: I give permission for the TERP Quest Summer Day Camp staff to assist in applying sunscreen to my child. I understand that this may require the staff member to touch my child s face, shoulders, back, arms, and lower legs. Sunscreen will be applied in the presence of other staff members. I understand that staff will not apply sunscreen to my child s front torso or upper legs, but will assist and/or direct the child to do so. In the event a camper does not bring sunscreen to camp and conditions warrant its use, by my signature below I authorize TERP Quest Staff to use emergency camp supplies of sunscreen. I also understand that repeated use of camp sunscreen may result in an additional charge to camp fees. Parent/Guardian Signature:_ Date: Printed Name : OR I DO NOT give permission for TERP Quest Summer Day Camp staff to assist in applying sunscreen to my child. Parent/Guardian Signature:_ Date: Printed Name :