What is the deadline for signing up for camp? You can sign up as long as there is space available up until the Friday before the session starts. If the camp you want is full, we are happy to add you to our waitlist. You will be called if we have an opening. There is no cost to join a waitlist, and no obligation to sign up once you re on it. Your best chance is to sign up early for our popular camps. Full payment is due at the time of registration. Is before and after care available? How about breakfast & lunch? Yes! For campers aged 6 12, our Before Care @ CARC opens at 7:30 a.m. and is a supervised, unstructured playtime until camp gets started. After Care @ CARC is open until 6 p.m. and is a supervised, unstructured playtime. You may add Before Care to any camp and After Care to any full-day or afternoon camp. All campers in Before Care and those enrolled in GGAC will have the opportunity to eat a provided breakfast. We offer supervised lunch and recess time at no charge for those campers signed up for both a morning AND afternoon session( or full -day camp) on the same day. Free breakfast and lunch are also offered to anyone under the age of 18,, Monday Friday, so campers may eat either at any time outside of camp with parent supervision. What if I need full-day camp? Build your camp week with combinations of morning and afternoon camps that include a free supervised lunch and recess, or choose from one of our full-day camps. Will I receive a refund if my child can t come to camp? If your child cannot attend a program and the College is notified at least 10 business days before it begins, we will issue a full refund. For notification with less than 10 business days, we will be happy to provide a refund less the camp fees which cover the cost of pre-purchased materials and non-refundable commitments to partners. No refunds are given once a camp begins. The College expects all programs to be presented as scheduled, however, a program could be cancelled due to insufficient enrollment. A decision about cancellation is made approximately 2-weeks before the start date of the camp. You will be notified via email. In the event that a program is cancelled, every effort will be made to either place your child in another program of his/her interest or provide a full refund. What s your tax ID number? How do I get a receipt? Our tax ID number is: 52-0906659. For a receipt for your payment, please contact the CARC Front Desk at 301.387.3786. How will I know if my camp is cancelled? We send important camp messages including schedule changes and cancellations via email. We need a valid email address for you. Please add maney.gale@garrettcollege.edu to your contact list. Do I have to fill out a new Health & Emergency Contact Form every year? Yes. A current Health & Emergency Contact Form is required for each participating child at least 2-weeks BEFORE the first day of his/her camp. A new form must be completed each year in order for your child to participate in camp.
For all camps: 1 filled water bottle, labeled with your name 1 bottle of sunscreen, labeled with your name Closed-toe shoes (sneakers, athletic shoes, etc.) Any required medication, along with a completed medication authorization form. A great attitude! For Great Garrett Adventure Camp: swimwear 1-2 towels For Mt. MD Music Institute: Musical instrument (if applicable) For Baseball Camp: Baseball glove Baseball cleats or tennis shoes Baseball hat Baseball bat (if you own one) For Adventure Sports Camp: Mountain bike (with pre-approval of instructor)
Camp Cost Dates Hours GREAT GARRETT ADVENTURE CAMP, Ages 6-12 FULL DAY Mad Scientist Training Academy $135 CARC / $165 Non-Member June 18-22 8:30 AM - 5:00 PM Junior Chef: Cooking $135 CARC / $165 Non-Member June 25-29 8:30 AM - 5:00 PM American Ninja Camper $135 CARC / $165 Non-Member July 9-13 8:30 AM - 5:00 PM S.T.E.A.M. Camp $135 CARC / $165 Non-Member July 16-20 8:30 AM - 5:00 PM Junior Chef: Baking $135 CARC / $165 Non-Member July 23-27 8:30 AM - 5:00 PM Curtain Call $135 CARC / $165 Non-Member Aug 6-10 8:30 AM - 5:00 PM Water, Water, Everywhere $135 CARC / $165 Non-Member Aug 13-17 8:30 AM - 5:00 PM HALF-DAY AM Mad Scientist Training Academy $75 CARC / $100 Non-Member June 18-22 8:30 AM - 12:00 PM Junior Chef: Cooking $75 CARC / $100 Non-Member June 25-29 8:30 AM - 12:00 PM American Ninja Camper $75 CARC / $100 Non-Member July 9-13 8:30 AM - 12:00 PM S.T.E.A.M. Camp $75 CARC / $100 Non-Member July 16-20 8:30 AM - 12:00 PM Junior Chef: Baking $75 CARC / $100 Non-Member July 23-27 8:30 AM - 12:00 PM Curtain Call $75 CARC / $100 Non-Member Aug 6-10 8:30 AM - 12:00 PM HALF-DAY PM (MON - THUR, Athletics/ASI AM Campers Only) Mad Scientist Training Academy $75 CARC / $100 Non-Member June 18-22 12:00 PM - 5:00 PM Junior Chef: Cooking $75 CARC / $100 Non-Member June 25-29 12:00 PM - 5:00 PM American Ninja Camper $75 CARC / $100 Non-Member July 9-13 12:00 PM - 5:00 PM S.T.E.A.M. Camp $75 CARC / $100 Non-Member July 16-20 12:00 PM - 5:00 PM Junior Chef: Baking $75 CARC / $100 Non-Member July 23-27 12:00 PM - 5:00 PM Curtain Call $75 CARC / $100 Non-Member Aug 6-10 12:00 PM - 5:00 PM OPTIONAL FRIDAY ADD-ON (Athletics/ASI AM Campers Only) Mad Scientist Training Academy $30 CARC / $40 Non-Member June 22 8:30 AM - 5:00 PM Junior Chef: Cooking $30 CARC / $40 Non-Member June 29 8:30 AM - 5:00 PM American Ninja Camper $30 CARC / $40 Non-Member July 13 8:30 AM - 5:00 PM S.T.E.A.M. Camp $30 CARC / $40 Non-Member July 20 8:30 AM - 5:00 PM Junior Chef: Baking $30 CARC / $40 Non-Member July 27 8:30 AM - 5:00 PM Curtain Call $30 CARC / $40 Non-Member Aug 10 8:30 AM - 5:00 PM MINI CARC CAMPS, Ages 4-10 Pokémon Academy $50 CARC / $75 Non-Member July 2-3 8:30 AM - 5:00 PM Art Attack $50 CARC / $75 Non-Member July 5-6 8:30 AM - 5:00 PM Location: Garrett College Community Aquatic & Recreation Complex (CARC) Camp Director: Maney Gale 301.387.3086 maney.gale@garrettcollege.edu
Camp Cost Dates Hours ADVENTURE SPORTS INSTITUTE DAY CAMPS Rock Climbing, Ages 7-9 $160 June 18-21 9:00 AM - 12:00 PM Rock Climbing, Ages 10-12 $160 June 25-28 9:00 AM - 12:00 PM Mountain Biking, Ages 7-9 $160 July 9-12 9:00 AM - 12:00 PM Mountain Biking, Ages 10-12 $160 July 16-19 9:00 AM - 12:00 PM Multi-Adventure Camp, Ages 7-9 $160 July 23-26 9:00 AM - 12:00 PM Multi-Adventure Camp, Ages 10-12 $160 Aug 6-9 9:00 AM - 12:00 PM MOUNTAIN MARYLAND MUSIC INSTITUTE High School Instrumental $225 July 9-13 9:00 AM - 5:00 PM Choral, Ages 8-11 $225 July 9-13 10:00 AM - 400 PM Middle School Instrumental $225 July 16-20 9:00 AM - 5:00 PM Choral, Ages 12-17 $225 July 16-20 9:00 AM - 5:00 PM GARRETT COLLEGE ATHLETIC CAMPS Lakers Basketball Camp, Ages 9-15 $75 June 18-21 9:00 AM - 12:00 PM Lakers Baseball Camp, Ages 6-13 $60 June 25-28 9:00 AM - 12:00 PM Adventure Sports Institute Camps Location: Garrett College Center for Adventure & Outdoor Studies (CAOS) (Meet every morning @ CARC) Camp Director: Scott Richardson 301.387.3323 scott.richardson@garrettcollege.edu Mountain Maryland Music Institute Location: Garrett College Music Department (800 building) Camp Director: Dr. Sean Beachy 301.387.3106 sean.beachy@garrettcollege.edu Garrett College Athletic Camps Location: Garrett College CARC Gym Basketball Camp Director: Dennis Gibson 301.387.3051 dennis.gibson@garrettcollege.edu Baseball Camp Director: Eric Hallenbeck 301.387.3331 eric.hallenbeck@garrettcollege.edu
Camp Cost Dates Hours BEFORE CARE @ CARC, Ages 6-12 Week 1 $25 June 18-22 7:30 AM - Camp Start Week 2 $25 June 25-29 7:30 AM - Camp Start Week 3 $25 July 9-13 7:30 AM - Camp Start Week 4 $25 July 16-20 7:30 AM - Camp Start Week 5 $25 July 23-27 7:30 AM - Camp Start Week 6 $25 Aug 6-10 7:30 AM - Camp Start Week 7 $25 Aug 13-17 7:30 AM - Camp Start AFTER CARE @ CARC, Ages 6-12 Week 1 $25 June 18-22 5:00 PM - 6:00 PM Week 2 $25 June 25-29 5:00 PM - 6:00 PM Week 3 $25 July 9-13 5:00 PM - 6:00 PM Week 4 $25 July 16-20 5:00 PM - 6:00 PM Week 5 $25 July 23-27 5:00 PM - 6:00 PM Week 6 $25 Aug 6-10 5:00 PM - 6:00 PM Week 7 $25 Aug 13-17 5:00 PM - 6:00 PM *Before Care until 10 AM & After Care from 4 PM available for MMMI Elementary Choral Campers. Location: Garrett College Community Aquatic & Recreation Complex (CARC) Camp Director: Maney Gale 301.387.3086 maney.gale@garrettcollege.edu Need a little extra time to pick up or drop off your camper? Optional before and after camp care sessions are available for busy parents and guardians. We drop your camper at their assigned camp in the morning. Their other camp will drop them back off to us for after care, if applicable.
Mad Scientist Training Academy Campers will explore science & engineering, unlock the power of chemical reactions, and unleash the awesomeness of the scientific method in their quest to become Mad Scientists. Curtain Call Campers will explore the world of theater through games, storytelling, script writing, voice and movement techniques, singing, dancing, and more as they design a skit, play, musical, or movie! Junior Chef: Cooking Campers will discover how fun and easy cooking can be while learning how to make delicious recipes, from main courses to desserts and snacks, with plenty of tasting along the way. Guest Chefs will introduce new dishes and techniques throughout the week. Water, Water, Everywhere Campers will splish and splash their way into learning everything about water, aquatics, and pool sports in engaging and exciting ways all while playing, swimming, and having fun! American Ninja Camper Campers will be jumping, flipping, climbing, swimming and conquering obstacle courses through an awesome week of camp, all in the pursuit of the title, American Ninja Camper! Ages 6 12 Campers must be 6 years old by September 1, 2018. S.T.E.A.M. Camp At S.T.E.A.M. Camp, campers don't just learn science, technology, engineering, arts, and mathematics. They make it. They create it. They build it. Junior Chef: Baking Campers will explore the delicious world of baking in this camp including pies, cakes, fillings, and other baked desserts with a nod to summer.
Rock Climbing Day Camp: Ages 7-9 Kids Rock Climbing Day Camp: Ages 10-12 Min.4 Max. 10. Participants will learn basic rock climbing techniques and fitness strategies to promote rock climbing skills and have fun meeting new kids. Adventure Sports certified rock climbing instructors will assist participants through Garrett College indoor climbing area to the outdoor 36 ft climbing tower and finally rock climbing at Fork Run climbing area near the ASCI white water course in McHenry MD. All equipment and transportation included in price. Mountain Biking Day Camp: Ages 7-9 Mountain Biking Day Camp: Ages 10-12 Min.4 Max. 8. Participants will learn basic riding skills, bike maintenance and obstacle course drills and fitness strategies to promote single track riding at local State Parks. Adventure Sports certified instructors will assist participants through fun biking games and drills to prepare participants for biking on single track trails. Participants must have basic bike riding skills to participate in day camps. Participants can use their own bikes if approved by instructors for safety purposes. Mountain bikes, helmets and transportation included in price. Multi-Adventure Day Camp: Ages 7-9 Multi-Adventure Day Camp: Ages 10-12 Min.4 Max. 10. Participants will engage in daily adventures that include: rock climbing, mountain biking, geo cashing, Challenge Course, and camping skills. Adventure Sports certified instructors will promote an educational week of adventure based activities that will promote fitness and fun educational topics in this exciting day camp adventures. All equipment and transportation provided in price.
Lakers Basketball Camp This camp offers high level drills that reinforce fundamental skills, effective position-specific offensive game moves and counter moves, as well as, improvement of on-ball and off-ball defense. Players will gain knowledge by practicing competitive game situations. Lakers Baseball Camp Baseball Camp Special Features: Games Played Every Day Baseball Olympics Events: 1. Ground balls 2. Radar Gun 3. Bunting Contest 4. Run bases for time 5. Throwing for Accuracy 6. Sunflower Seed Spitting Contest Camp Philosophy: Teach the basic fundamentals of the game of baseball. Hitting, fielding, throwing, bunting, base running, and sliding will be covered throughout the week.
The Mountain Maryland Music Institute is an exciting summer enrichment program located at Garrett College in the beautiful mountains of Western Maryland. Participants will focus on technique, repertoire, and music theory through expert group and individual instruction. Focus on ensemble rehearsal and performance in concert band and choir setting Expert instruction by regional educators and performing artists Individual and group instruction Emphasis on music theory and musicianship Traditional camp activities including swimming and indoor rock climbing Offering: High School Instrumental Middle School Instrumental Choral, Ages 8 11 Choral, Ages 12 17 Pokémon Academy Calling all Pokémon trainers! Improve your reading, writing, math, geography and science knowledge through the world of Pokémon. Create your own unique Pokémon creature. Battle your friends with new powers and moves. Create a story for you and your Pokémon along with art projects to complete your set. Get ready because I choose you! Art Attack Let your creativity run wild with this two-day, art-filled camp. Campers will attack art from every direction all while finding new ways to express themselves, and have fun learning a variety of art forms from outstanding instructors.
2018 Registration, Health, & Emergency Form This form must be completed for each child and received at the GC CARC no later than one week prior to first camp. You may fax the completed form to Maney Gale at 301.387.3789 or email scanned forms to maney.gale@garrettcollege.,edu Visit www.garrettcollege.edu/camps to print additional forms or to complete online. Contact Information Email: Child s Full Legal Name: Child s Preferred Name: - Child s Date of Birth: Sex: M F Grade 2018/19 school year: Street: City: State: Zip: Guardian 1 Name: Home Phone: Work: Cell: Guardian 2 Name: Home Phone: Work: Cell: Name(s) of Additional Authorized Adult(s) picking up the student: Same as above plus: In an emergency contact: Parent(s) as listed above first, then: (Please supply at least one.) Name: Relation to Child: Home Phone: Work: Cell: Name: Relation to Child: Home Phone: Work: Cell: Immunization/Health Information Camper s Physician s Name: Phone Number: For campers who reside WITHIN the United States, a United States Territory, or the District of Columbia: State/territory in which child resides: Is this child exempt from any immunizations? No Yes, list them: For campers who reside OUTSIDE the United States, a United States territory, or the District of Columbia: 1. Country in which child resides: 2. Attach Department form DHMH-896 (record of vaccination or immunity) (continued on reverse)
Child s Full Name: Immunization/Health Information (continued) Please tell us about any allergies. Mark all that apply: None that I know about Bee sting Peanuts/other nuts Other: My child carries an EpiPen Is this a life threatening allergy? Yes No Yes No Yes No Please list any medications, dietary restrictions or special needs your child may have so we can ensure a positive camp experience: None Are there any other physical, psychiatric, behavioral or emotional conditions of which we need to be aware? Mark all that apply: None Asthma ADD Diabetes Emotional issues Epilepsy/seizure Hearing impairment Asperger s/autism Other (please explain) If your child has needs that require special attention, please e-mail us at maney.gale@garrettcollege.edu at least four weeks in advance so we can do our best to accommodate them. If your child must either carry or be given ANY medication during program hours, the Medication Administration Authorization Form is required by the MD State Department of Health. No medication will be accepted without the completed Authorization form. Access the form at http://bit.do/campmeds, in the pre-camp email that you receive with your confirmation or call 301.387.3786. IN THE EVENT OF AN EMERGENCY, you agree to release and hold harmless Garrett College, whose first aid certified staff may administer first aid to your child as needed and authorize Garrett College staff to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for your child s immediate care and agree to be responsible for payment of any and all charges for medical services rendered. PHOTO RELEASE My child has my permission to be photographed, interviewed, or videotaped while attending any Garrett College Camp for possible use in print or web marketing. I release Garrett College, its Board of Trustees, officers, agents, directors, faculty/staff, and assigns from any and all claims (monetary or otherwise) that you may have related to the use of these images. FIELD TRIPS Yes No I give permission for my child participate in camp field trips (as applicable), 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. Yes No SUNSCREEN 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 give Garrett College Camp Staff permission to apply, or supervise the application of an SPF sunscreen that I have provided for my child should they require and ask for assistance. Yes No (continued on next page)
Camp Information My child will be attending the following camps: Camp Cost Dates Hours Select GREAT GARRETT ADVENTURE CAMP, Ages 6-12 FULL DAY Mad Scientist Training Academy $135 CARC / $165 Non-Member June 18-22 8:30 AM - 5:00 PM Junior Chef: Cooking $135 CARC / $165 Non-Member June 25-29 8:30 AM - 5:00 PM American Ninja Camper $135 CARC / $165 Non-Member July 9-13 8:30 AM - 5:00 PM S.T.E.A.M. Camp $135 CARC / $165 Non-Member July 16-20 8:30 AM - 5:00 PM Junior Chef: Baking $135 CARC / $165 Non-Member July 23-27 8:30 AM - 5:00 PM Curtain Call $135 CARC / $165 Non-Member Aug 6-10 8:30 AM - 5:00 PM Water, Water, Everywhere $135 CARC / $165 Non-Member Aug 13-17 8:30 AM - 5:00 PM HALF-DAY AM Mad Scientist Training Academy $75 CARC / $100 Non-Member June 18-22 8:30 AM - 12:00 PM Junior Chef: Cooking $75 CARC / $100 Non-Member June 25-29 8:30 AM - 12:00 PM American Ninja Camper $75 CARC / $100 Non-Member July 9-13 8:30 AM - 12:00 PM S.T.E.A.M. Camp $75 CARC / $100 Non-Member July 16-20 8:30 AM - 12:00 PM Junior Chef: Baking $75 CARC / $100 Non-Member July 23-27 8:30 AM - 12:00 PM Curtain Call $75 CARC / $100 Non-Member Aug 6-10 8:30 AM - 12:00 PM HALF-DAY PM (MON - THUR, Athletics/ASI AM Campers Only) Mad Scientist Training Academy $75 CARC / $100 Non-Member June 18-22 12:00 PM - 5:00 PM Junior Chef: Cooking $75 CARC / $100 Non-Member June 25-29 12:00 PM - 5:00 PM American Ninja Camper $75 CARC / $100 Non-Member July 9-13 12:00 PM - 5:00 PM S.T.E.A.M. Camp $75 CARC / $100 Non-Member July 16-20 12:00 PM - 5:00 PM Junior Chef: Baking $75 CARC / $100 Non-Member July 23-27 12:00 PM - 5:00 PM Curtain Call $75 CARC / $100 Non-Member Aug 6-10 12:00 PM - 5:00 PM OPTIONAL FRIDAY ADD-ON (Athletics/ASI AM Campers Only) Mad Scientist Training Academy $30 CARC / $40 Non-Member June 22 8:30 AM - 5:00 PM Junior Chef: Cooking $30 CARC / $40 Non-Member June 29 8:30 AM - 5:00 PM American Ninja Camper $30 CARC / $40 Non-Member July 13 8:30 AM - 5:00 PM S.T.E.A.M. Camp $30 CARC / $40 Non-Member July 20 8:30 AM - 5:00 PM Junior Chef: Baking $30 CARC / $40 Non-Member July 27 8:30 AM - 5:00 PM Curtain Call $30 CARC / $40 Non-Member Aug 10 8:30 AM - 5:00 PM MINI CARC CAMPS, Ages 4-10 Pokémon Academy $50 CARC / $75 Non-Member July 2-3 8:30 AM - 5:00 PM Art Attack $50 CARC / $75 Non-Member July 5-6 8:30 AM - 5:00 PM ADVENTURE SPORTS INSTITUTE DAY CAMPS Rock Climbing, Ages 7-9 $160 June 18-21 9:00 AM - 12:00 PM Rock Climbing, Ages 10-12 $160 June 25-28 9:00 AM - 12:00 PM Mountain Biking, Ages 7-9 $160 July 9-12 9:00 AM - 12:00 PM Mountain Biking, Ages 10-12 $160 July 16-19 9:00 AM - 12:00 PM Multi-Adventure Camp, Ages 7-9 $160 July 23-26 9:00 AM - 12:00 PM Multi-Adventure Camp, Ages 10-12 $160 Aug 6-9 9:00 AM - 12:00 PM (continued on reverse)
MOUNTAIN MARYLAND MUSIC INSTITUTE High School Instrumental $225 July 9-13 9:00 AM - 5:00 PM Choral, Ages 8-11 $225 July 9-13 10:00 AM - 400 PM Middle School Instrumental $225 July 16-20 9:00 AM - 5:00 PM Choral, Ages 12-17 $225 July 16-20 9:00 AM - 5:00 PM GARRETT COLLEGE ATHLETIC CAMPS Lakers Basketball Camp, Ages 9-15 $75 June 18-21 9:00 AM - 12:00 PM Lakers Baseball Camp, Ages 6-13 $60 June 25-28 9:00 AM - 12:00 PM BEFORE CARE @ CARC, Ages 6-12 Week 1 $25 June 18-22 7:30 AM - Camp Start Week 2 $25 June 25-29 7:30 AM - Camp Start Week 3 $25 July 9-13 7:30 AM - Camp Start Week 4 $25 July 16-20 7:30 AM - Camp Start Week 5 $25 July 23-27 7:30 AM - Camp Start Week 6 $25 Aug 6-10 7:30 AM - Camp Start Week 7 $25 Aug 13-17 7:30 AM - Camp Start AFTER CARE @ CARC, Ages 6-12 Week 1 $25 June 18-22 Camp End - 6:00 PM Week 2 $25 June 25-29 Camp End - 6:00 PM Week 3 $25 July 9-13 Camp End - 6:00 PM Week 4 $25 July 16-20 Camp End - 6:00 PM Week 5 $25 July 23-27 Camp End - 6:00 PM Week 6 $25 Aug 6-10 Camp End - 6:00 PM Week 7 $25 Aug 13-17 Camp End - 6:00 PM TIMELY PICK-UP 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. Late fees may be assessed for multiple late pick-ups. Habitual late pick-ups may result in suspension or termination of your child s enrollment in the program. INFORMED CONSENT/ASSUMPTION OF RISK I have registered my child summer camp sponsored by Garrett College. I understand that participation in this activity/course involves inherent risks of injury, and that the nature of the risks may vary depending upon the type of activity, instructor, and my child s physical condition and conduct. I acknowledge that I will either ask for or have been given any information that I need to determine the general risks associated with this camp and its activities. I agree that my child will follow advised precautions and conform to all rules and policies of the department, instructor, and any other sponsor of this course/activity. I voluntarily assume all risks of loss, damage, illness, or injury which my child may sustain while participating in this camp and its activities, including travel and usage of any equipment or facilities. I will make no claim against and do hereby fully and unconditionally, forever release, waive, discharge, hold harmless and indemnify, on behalf of myself (my child), my personal representatives and my heirs, Garrett College and its Board of Trustees, officers, agents, and employees from any and all claims and causes of action for any injury or loss, or for damages, costs, expenses, or compensation that may occur during or result from my child s participation in this camp and its activities, whether arising through the negligence, omission, default, or other action of any person or event associated with this course or event, including fellow participants. I have read and understand the above information. I give my permission for my child to participate in this camp and its activities and grant the same informed consent, assumption of risk, and release for myself (for my child), estate, successors, and assigns, and the child s family. Parent/Guardian Signature: (required) Date: Printed name of Parent or Guardian
MEDICATION ADMINISTRATION AUTHORIZATION FORM for Youth Camps in Maryland Maryland Department of Health (MDH) Center for Healthy Homes and Community Services (CHHCS) (410) 767-8417 Toll Free 1-877-4MD-MDH ext. 8417 This form must be completed fully in order for youth camp operators and staff members to administer the required medication or for the camper to self-administer medication. A new medication administration form must be completed at the beginning of each camp season, for each medication, and each time there is a change in dosage or time of administration of a medication. Prescription medication must be in a container labeled by the pharmacist or prescriber. Nonprescription medication must be in the original container with the instructions for use. Nonprescription medication includes vitamins, homeopathic, and herbal medicines. An authorized individual must bring the medication to the camp and give the medication to an adult staff member. I. PRESCRIBER S AUTHORIZATION 1. CHILD S NAME 2. DATE OF BIRTH / / Month Day Year 3. CONDITION FOR WHICH MEDICATION IS BEING ADMINISTERED: 4. EMERGENCY MEDICATION [ ] YES -If yes, see Section III below. [ ] NO 5. MEDICATION NAME 6. DOSE 7. ROUTE 8. TIME/FREQUENCY OF ADMINISTRATION 9. IF PRN, FREQUENCY 10. IF PRN, FOR WHAT SYMPTOMS 11. KNOWN SIDE EFFECTS SPECIFIC TO CHILD 12. MEDICATION SHALL BE ADMINISTERED during the year in which this form is dated in 14b below unless more restrictive dates are specified in 12a and 12b. This authorization is NOT TO EXCEED 1 YEAR. 12a. FROM / / Month Day Year 12b. TO / / Month Day Year 13. PRESCRIBER S NAME/TITLE This space may be used for the Prescriber s Address Stamp TELEPHONE FAX ADDRESS CITY STATE ZIPCODE 14a. PRESCRIBER S SIGNATURE (Parent/guardian cannot sign here) (ORIGINAL SIGNATURE OR SIGNATURE STAMP ONLY) II. PARENT/GUARDIAN AUTHORIZATION 14b. DATE I request the authorized youth camp operator, staff member or volunteer to administer the medication or supervise the camper in self-administration as prescribed by the above authorized prescriber. I certify that I have legal authority to consent to medical treatment for the child named above, including the administration of medication at the facility. I understand that at the end of the authorized period, an authorized individual, as listed in 15c below, which may include the child, must pick up the medication, otherwise it will be discarded. I authorize camp personnel and the authorized prescriber indicated on this form to communicate in compliance with HIPAA. 15a. PARENT/GUARDIAN SIGNATURE 15b. DATE 15C. INDIVIDUAL(S) AUTHORIZED TO PICK UP MEDICATION 15d. HOME PHONE # 15e. CELL PHONE # 15f. WORK PHONE # III. AUTHORIZATION FOR SELF-ADMINISTRATION / SELF-CARRY (OPTIONAL) This section should only be completed if this medication is approved for self-administration. Self-carry is only permitted for emergency medications such as inhalers and epinephrine. Both the prescriber and the parent/guardian must consent to self-administration below. However, youth camp operators are not required to permit self-administration or self-carry. I authorize self-administration of the above listed medication for the child named above under the supervision of the youth camp operator, a designated staff member or volunteer. If indicated below, the child named above may self-carry emergency medication. 16a. PRESCRIBER S SIGNATURE authorizing self-administration 16b. SELF-CARRY EMERGENCY MEDICATION (Check One) [ ] YES [ ] NO [ ] N/A - Not emergency medication 16c. DATE 17a. PARENT/GUARDIAN S SIGNATURE authorizing self-administration 17b. SELF-CARRY EMERGENCY MEDICATION (Check One) [ ] YES [ ] NO [ ] N/A - Not emergency medication 17c. DATE MDH-4758 (01/2017) KEEP FOR 3 YEARS Page 1 of 1