Returning Staff Registration 2021

Returning Staff Registration 2021

Complete the form below and submit no later than January 15th.
General Information
First Name: *
Last Name *
Camp Name: *
Date of Birth *

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Day Phone: *

Area Code Phone Number
Evening Phone: *

Area Code Phone Number
Cell Phone: *

Area Code Phone Number
Primary Email for receiving camp forms: *
Currently a Girl Scout? *

Yes No
This will be year _____ for you at Roundup (2, 3, 4...33). *
T-Shirt Size: *

YS YM YL AS AM AL AXL A2X
Additional Emergency Contact: *
Relation: *
Phone Number *

Area Code Phone Number
Do you wish to stay in the same unit as your daughter?

Yes No No preference or N/A
Program and Camping information
Program you would like to work with:

Tagalongs Daisy/Brownie Brownie Junior Cadette High School Summer Roundup Leadership Academy UNIT LEADER KITCHEN NURSE CRAFTS BOATING LIFEGUARDING ZIP LINE ARCHERY YOGA SELF DEFENSE
Certifications held - I will need copies for our records:

CPR 1st Aid Basic Leadership Camping Basics Nursing Program Aide Counselor in Training (Advanced Program Aide) Counselor in Training II Zip Line High Ropes Boating Archery Log Rolling Lifeguard Swimming Lessons Other
Health Information
Are there any new health problems including physical, psychiatric, or behavioral problems of which we need to be aware?
Date of last physical (GSCB recommends every 2 years for those attending camp): *

Month Day Year
Name of Physician: *
Phone Number *

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Name of Dentist: *
Phone Number *

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Insurance Information
Is participant covered by family medical/hospital insurance? *

Yes No
Name of Insurance Company:
Company Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number

Area Code Phone Number
Policy Number:
Group Number:
Name of Insured:
Relationship to Camper:
Health History
The following informaiton must be filled out by the parent/guardian or adult camper or staff member over the age of 18. The intent of this information is to provide the camp health care personnnel the background to provide appropriate care. Keep a copy of the completed form for your records. Any changes to this form should be provided to camp health personnel upon participant's arrival at camp. Provide complete information so that the camp can be aware of your needs.
IMMUNIZATIONS

Please fill out either the left hand questions (if US Citizen) or right hand questions (if not a US Citizen).
State/Territory in which person resides: *
Country in which person resides:
Is person exempt from any immunizations? *

Yes No
If yes, explain:
Provide Department form DHMH-896 from the

Maryland Department of Health and Mental Hygene.

(record of vaccination or immunity)

Upload or Mail form to the Camp Director.
Upload DHMH-896
Please check any allergies or food preferences that you have: *

Spider/Bee/Tick allergy Medication allergy Epi Pen Latex allergy Medically prescribed diet Mom-medical dietary restrictions Does not eat red meat Does not eat pork Does not eat poultry Does not eat seafood Does not eat eggs Lactose intollerant Vegetarian Egg Allergy Dairy Allergy Gluten Allergy Seafood or Shellfish Allergy Other food allergy or preference Red Dye None
Please describe any allergy or intolerance (i.e. diarrhea, cramps, headache, hives, etc.), or state allergy not listed above and state any allergic reactions or symptoms.
Do you take daily medication?

Yes - Prescription medication Yes - Over the counter medication Yes - Other No
By checking this box, you agree that you are in good health and may participate in camp activities, including field trips to non-council properties; that you give your permission for medical treatment if necessary; that you (or your teen) will not attend camp if you (or she) becomes exposed to any contagious disease; and that you give your permission to be photographed/videographed for publicity purposes. Check that you agree to comply with all camp regulations. *

I agree I do not agree
I give permission to the designated adult to administer the above medications as indicated (a physician's signature is required). This health history is correct and complete as far as I know, and the person herein described has permission to engage in all camp activities except as noted. I hereby give permission to the medical personnel selected by the camp director to order x-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me/my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out of camp. *

I agree No, I do not agree
By checking this box, you agree that you will comply with any and all medical restrictions placed upon you by your physician if applicable. *

I agree No, I do not agree
If for religious reasons, you cannot sign this, contact the camp director for a legal waiver which must be signed for attendance. Call Amy Schisler at 410-725-1693 or email amyschisler@me.com
All Non-Girl Scouts, including adults, MUST be registered as a Scout in order to be covered by our insurance. If you are not already a registered Girl Scout, please follow the link to PERSONIFY on the forms page or in your confirmation email. A copy of your registration receipt must be sent to amyschisler@me.com
Teen Camp Aides are required to pay a $25 fee. Payment Options:

I will pay now with PayPal Check will be mailed by June 1st.
PayPal Payment - DO NOT check an option unless you are making a payment.
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$25 Camp Fee for Teen Program Aides Only $ 25.00

OPTIONAL Donation to the Summer Roundup Program Aide College Scholarship Free

Scholarship Donation
For questions regarding camping, paying, or volunteering, call Amy Schisler at 410-725-1693 or email amyschisler@me.com
Date and Time

Month Day Year Hour Minutes AM/PM Option
Should be Empty:

Returning Staff Registration 2021

General Information

Program and Camping information

Health Information

Insurance Information

Health History

For questions regarding camping, paying, or volunteering, call Amy Schisler at 410-725-1693 or email amyschisler@me.com