First Time Staff Registration 2021

First Time Staff Registration 2021

Complete the form below and submit no later than May 1st.
General Information
First Name: *
Last Name *
Your Camp Name: *
Birth Date *

Month Day Year
Already a Girl Scout? *

Yes No
Have you attended Summer Roundup before? *

Yes No
This will be your _____ year at Roundup - 1st, 2nd, 3rd, etc.??
Council: *
T-Shirt Size: *

YS YM YL AS AM AL AXL A2X
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Day Phone: *

Area Code Phone Number
Evening Phone: *

Area Code Phone Number
Cell Phone: *

Area Code Phone Number
Primary Email for receiving camp forms: *
Additional Emergency Contact: *
Phone Number *

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

Yes No No preference
Program and Camping information
Girl Scout Level You prefer:

Daisy Brownie Junior Teen
Program you would like to work with:

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

CPR 1st Aid Basic Leadership Camping Basics Program Aide Leader in Training (Advanced Program Aide) Zip Line Boating Archery Lifeguard Nursing Other
Why do you want to volunteer at Roundup?
Health Information
Gender
Are there any 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
Please check all that apply: Has/Does the participant: *

had any recent illness, injury, or infectious disease? have a chronic or recurring illness or condition? have frequent headaches? wear glasses, contacts, or protective eye wear? have frequent ear infections? ever had seizures? ever had chest pain during or after exercise? have high blood pressure? ever been diagnosed with a heart murmur or condition? ever had back problems? have an orthopedic appliance being brought to camp? have any frequent or recurring skin problems (itching, rash, acne, atopic dermatitis)? have asthma? have diabetes? had mononucleosis in the past 12 months? had problems with diarrhea or constipation? have an eating disorder? none of the above?
Please explain any checked areas.
Please use this space to provide any additional information about the participant's behavior and physical, emotional, or mental health about which the camp staff should be aware. Be sure to let us know your child's fears about camp, sleeping habits, bed wetting, and/or other pertinent information that will help to make your child's stay at camp the best it can be.
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
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.
If yes, explain:
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
Please list ALL medications (including over the counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire stay at camp. Keep it in the original packaging/bottle that identifies the prescribing physician (if it is a prescription drug), the name of the medication, the dosage, and the frequency of administration.

MARYLAND STATE LAW REQUIRES WRITTEN PHYSICIAN PERMISSION FOR ALL MEDICATION TAKEN AT CAMP, PRESCRIPTION AND OVER THE COUNTER. PLEASE PRINT THE MEDICATION AUTHORIZATION FORM FROM THE ROUNDUP WEB SITE AND SIGN IT. OBTAIN YOUR PHYSICIAN'S SIGNATURE, AND RETURN IT VIA EMAIL OR MAIL TO THE CAMP DIRECTOR. YOU MUST FILL OUT ONE FORM FOR EACH MEDICATION, PRESCRIPTION AND OVER THE COUNTER.
This person takes the following medication(s). Please list the names of the medications, the dosage, the times of day to be taken, and the reason for taking.
Explain any restrictions to activity (e.g. what cannot be done, what adaptations or limitations are necessary).
During the event that minor discomforts may occur, the following medications will be carried by the designated first aid adult or nurse. Please note which medications may or may not be given. Medication dosage will be given per weight/age as indicated in medication instructions.

MARYLAND STATE LAW NOW REQUIRES WRITTEN PHYSICIAN PERMISSION FOR ALL MEDICATION TAKEN AT CAMP, PRESCRIPTION AND OVER THE COUNTER. PLEASE PRINT THE MEDICATION AUTHORIZATION FORM FROM THE ROUNDUP WEB SITE AND SIGN IT. OBTAIN YOUR PHYSICIAN'S SIGNATURE, AND RETURN IT VIA EMAIL OR MAIL TO THE CAMP DIRECTOR. YOU MUST FILL OUT ONE FORM FOR EACH MEDICATION, PRESCRIPTION AND OVER THE COUNTER.

Medicaitons that will be availbale at camp are limited to the following:

Acetaminophen/Tylenol - for headache, cramps, minor discomfort

Ibuprofin/Motrin/Advil

A&D Ointment - for chafing

Antacis Tablets (Tums/Rolaids) - upset stomach, heartburn

Anti-itch cream (Benadryl, Cortisone) - insect bites, minor itching

Calamine lotion - poison ivy

Cough Drops - cough, sore throat

Diphenhydramine HCL (Benadryl) - allergic reactions

Hydrogen Peroxide - minors cuts and scrapes

Triple Antibiotic Ointment (Neosporin) - minor cuts and scrapes

PLEASE PRINT THE MEDICATION AUTHORIZATION FORM FOR EACH OF THE ABOVE MEDICATIOS THAT YOUR CHILD IS ALLOWED TO TAKE.
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.
Payl Pal Payment
prev next ( X )
$25 Camp Fee for Teen Camp Aides $ 25.00
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:

First Time 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