Camp Zena Detailed Registration Form

Camper Information

Camper's Name*

First NameLast NameNickname

Birth Date*

MonthDayYear

Grade in Fall 2023*

Gender*

MaleFemale

Preferred pronouns*

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Parent/Guardian #1*

First NameLast Name

Cell Number*

Work Number

E-mail*

example@example.com

Parent/Guardian # 2

First NameLast Name

Cell Number

Please enter a valid phone number.

Work Number

Please enter a valid phone number.

Email

example@example.com

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Alt. Phone Number

What should we know about your camper (fears, likes, dislikes, special needs, etc?)

Please let us know the camper's swimming ability:*

Cannot swim, yet!Starting to swim (beginning to float)Some experience (confidence growing, working on strokes to swim length of pool)Expert swimmer (has passed diving board swim test)

COVID-19 Precautions:

Please be aware that there is risk associated with activities at day camps. Because we are in an outdoor environment, the risk is lower, but not eliminated entirely. To minimize risk and protect the safety of all campers and staff, Camp Zena will follow all applicable CDC and NYS Guidelines published for Day Camps this summer. These will be communicated separately as they are updated for summer.

Camper Health History - CONFIDENTIAL

Child's Physician*

First NameLast Name

Physician Phone #*

Please enter a valid phone number.

Date of Last Physical*

Date

Insurance Information

Insurance CarrierIdentification #Group #

Name of InsuredRelationship to Child

Allergies

Medications Enter allergies   Describe reaction
Foods Enter allergies   Describe reaction
Insect Stings   Enter allergies   Describe reaction
Environment (hay fever, pollen, etc)   Enter allergies   Describe reaction

Dietary modifications or restrictions   Enter here

Medications

Will the camper be self-administering any medication while at camp?*

YesNo

** If the camper will be self-administering medication while at camp, a copy of the doctor's prescription or order MUST be kept at camp in your child's file. Please enter info below:

Medication enter here
Dose enter here
How often enter here

Is the camper prescribed an inhaler, Epi Pen, or Insulin? If yes, please explain any instructions:

Please list all medications that the camper is currently taking at home. Camp Zena staff will not administer or store any medications at the camp. Please contact the Camp Director or staff form more information.

Medication enter here Dose enter here How Often enter here

IMMUNIZATIONS

A complete immunization series record is required for camp attendance. Camp Zena's policy is that campers need to be FULLY vaccinated in order to attend camp. Please upload a copy of the camper's immunization record from their medical provider. Please make sure the record clearly shows all dates and vaccines. If vaccinated for COVID-19, please include that as well.

Upload vaccinations here:*

Does your child wear glasses, contacts, or eye protection?*

YesNo

Does your child wear hearing aids?*

YesNo

Does your child wear an orthodontic appliance?*

YesNo

Does your child have asthma?*

YesNo

Does your child have diabetes?*

YesNo

Does your child have a seizure disorder?*

YesNo

Has your child had a concussion?*

YesNo

Does your child have sickle cell disease or trait?*

YesNo

Does your child learning disorder or ADD/ADHA?*

YesNo

Does your child have depression or other emotional issues?*

YesNo

Does your child require ear plugs when swimming?*

YesNo

Does your child have an eating disorder?*

YesNo

Does your child have heart problems such as a defect, disease, or murmur?*

YesNo

Does your child have skin problems like itching, rash or acne?*

YesNo

Has your child had recent mononucleosis?*

YesNo

Does your child have hepatitis?*

YesNo

If yes,

ABC

Does your child have a severe allergic reaction?*

YesNo

Had your child had tuberculosis?*

YesNo

Has your child had frequent ear infections?*

YesNo

Has your child ever fainted?*

YesNo

If you've answered yes to any of the above questions, please use this additional space to provide details of these issues as well as a plan of how Camp Zena can address these issues. If any of these issues requires an emergency plan, please outline that plan here as well.

Does your child have any activity restrictions?*

YesNo

If yes, please describe these restrictions:

Is there any additional information about the camper's behavior and physical, emotional or mental health that Camp Zena should be aware of:

I hereby give permission to the camp director, or qualified camp counselor, or lifeguard to administer first aid to my child.*

YesNo

In the event I cannot be reached in an emergency requiring immediate medical care, I hereby give permission to the camp director or designated camp counselors to call 911. This may result in transport by ambulance to a local hospital for the camp participant.*

YesNo

Permission to supervise application of topical items such as sunscreen, bug spray, lip balm etc.

Type of topical item enter here
Prescription # enter here
Start Date   Date
End Date   Date
Days of the week to be taken   enter here

I request that the camp staff supervise my child taking the above medication or applying the topical items as indicated.

YesNo

CAMP ZENA PHOTO RELEASE POLICY

I permit Camp Zena to take photos, videos and sound clips of my camper and my camper's projects at camp and to use them at its discretion.

Confirmation Acknowledging and signing below attests that you agree to our COVID-19 Policy, our Photo Release Policy, and that this form is filled out as factually as possible.

Signature*

Powered by Jotform Sign Clear

Would you like to be contacted for add-on swimming and tennis lessons for your camper?*

YesNo

Please select the week(s) for which you are registering your camper.

All prices noted include applicable sales tax.

**If paying by check, please enter coupon code CHECK and mail your check to:

Camp Zena

P.O. Box 688

Woodstock, NY 12498

We will reach out to all registrants about adding on swimming or tennis lessons at a later date. Priority will be given to Zena Rec members. Please note, if you'd like your camper to take swimming lessons, you must sign up for 2 consecutive weeks as follows:

Weeks 2&3

Weeks 4&5

Weeks 6&7

No group swim lessons are planned for weeks 1, 8 or 9. Private lessons can be arranged these weeks if interested.

Tennis lessons can be taken during any session week.

**If signing up multiple campers from the same family, please enter coupon code SIBLING for a 10% discount for the 2nd, 3rd, 4th, etc camper from that family.

** If signing up for all 9 weeks, please enter coupon code 9WEEKS for a 10% total discount.

If a week is sold out that you'd like to register for, please email camp@zenarec.com to be added to the waitlist.

Please note our refund policy -- If camp sessions are cancelled before May 15, 2023, a 50% refund will be returned. If cancelled after May 15, 2023, there will be no refund.

*

Day Camp: Week 1 June 26-30