Camp Creekside Enrollment

Dear Creekside Families,

We are excited to welcome you for another great summer at Camp Creekside! Below are the camp enrollment forms that must be completed by June 1:

Parental Permissions
Emergency Medical Form
Academic Goals

In addition, a non-refundable $500 deposit is due by April 14th to hold your child’s place. The remaining balance ($1375 without keyboarding, $1450 with keyboarding) is due by June 1st.

We interact with our families through the Remind App. You can install the app and use the class code (@gaghkc) to sign up for messages, or send a text to 81010 with the message @gaghkc.

Can’t wait to see you!

Jeremy Bullinger and Keri Knisley, Creekside Directors

jbullinger@camperdown.org / (864)561-5874
kknisley@camperdown.org / (765)716-1901

Student Information
Student's Name *

First Name Last Name
Gender *

Male Female
Birth Date

Month Day Year
Birth Date *

Month Day Year
Mobile Number *

Area Code Phone Number
Mobile Number 2

Area Code Phone Number
E-mail

Parental Permissions
Media

Whereas Camp Creekside is an educational resource for the area, your child might come in contact with professionals who are visiting. Some students might appear in photographs, films, or videotapes made in conjunction with the development of the camp or school. Photographs and videos will be taken during off-grounds trips for the purpose of sharing in an end-of-camp slideshow as an unlisted YouTube video and shared to a private social media account (@CampCreekside Instagram). Photos may also be shared on the Camperdown Academy Facebook and/or Instagram page. Names are never shared.
*

I give my consent for my child to appear in any media for Camp Creekside of Camperdown Academy. I do not give my consent for my child to appear in any media for Camp Creekside of Camperdown Academy.
Field trips

My child has permission to be transported to and from Camp Creekside (Camperdown Academy) at any time during the summer program with any employee or agent designated by the camp. I hereby release Camp Creekside and Camperdown Academy, its officers, directors, agents, and employees from any liability arising from field trips.
Parent or Guardian Signature

Clear
Date

Month Day Year
Date

Permission to Administer First Aid and Medication
Permission to Administer First Aid and Medication

Prescription medication will only be given to a student when the medication is sent to the school in a pill container, clearly labeled with the name of the student and the days of the week, and the appropriate medication placed in the proper section by the parent. Any type of over-the-counter medication must be brought from home with the student’s name on it, and left in the front office. I understand that a licensed nurse is not employed by, nor on the premises of, Camp Creekside. Every effort will be made to contact parent(s) and/or guardian(s) before any treatment is administered.
*

I give permission for camp personnel to administer first aid or over-the-counter medication as necessary. I do not give permission for camp personnel to administer first aid or over-the-counter medication as necessary.

Emergency Medical Form
Emergency Medical Form

This form will enable Camp Creekside to provide necessary medical information to emergency personnel in the event of an emergency. Please provide all relevant information so your child can receive immediate medical attention if necessary. Every effort will be made to contact parent(s)/guardian(s) before any treatment is administered.
Medical Insurance Carrier
Policy Number
Insured Name
Physician
Physician Phone
Dentist
Dentist Phone
Emergency Contacts
Name
Relationship
Phone
Name
Relationship
Phone
Please indicate any medical history/information of which emergency medical personnel should be aware (For example, diabetes, epilepsy, asthma, etc.)?
Medical Information
Please list any food or drug allergies that your child has. If none, please write n/a.
Allergies *
Please list all medications the student is currently taking, both at home and at camp. It is important to know what medication is being given at home in case an adverse reaction occurs at school. In that event, the parent and, if necessary, the child’s doctor, will be contacted immediately.
Medication / Dosage / Time
Last Diptheria/Tetanus/Tetanus booster

Month Day Year
Date
In the event of a medical emergency, I hereby give permission to the medical personnel selected by employees of Camp Creekside (Camperdown Academy) to order x-rays, routine tests, and/or other treatment for the above named child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by Camp Creekside (Camperdown Academy) to hospitalize, secure proper treatment for, and to order injections, anesthesia, and/or surgery for my child as named above. This completed form may be photocopied for off-grounds trips. I hereby agree to hold Camp Creekside (Camperdown Academy) it’s officers, directors, agents, and employees harmless from any liability arising from medical treatment of my child by a licensed healthcare provider.
Parent or Guardian Signature

Clear
Date

Month Day Year
Date

Authorized Pickup
Name / Relationship

Submission
Should be Empty: