Skyhook Camp Registration Form

Camper Information

Camper's Name*

First NameLast Name

Gender

Gender/ Title/ Pronouns, etc.

Birth Date*

MonthDayYear

Camper (2) Information

**If you are only registering one camper, please skip to "Parent/Guardian Information."

Camper's Name (2)

First NameLast Name

Birth Date (2)

MonthDayYear

Gender (2)

Gender/ Title/ Pronouns, etc.

Parent/Guardian Information

Name

First NameLast Name

Home Number

Cell Number

E-mail

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Alt. Phone Number

Approved Pick Up List

** All parents/guardians will need to provide some form of legal identification before we will release a camper. If anyone other than the listed parent will be picking up your camp, please list them below.

Adults/Guardians that I approve to pick up my child

	First Name	Last Name	Phone Number
1.
2.
3.
4.
5.

Allergy/Medical Conditions

My Camper Has Known Allergies

YesNo

If you answer "Yes" to the question above, please list all known allergies in the text field below. Please include the severity of the allergic reaction and protocol in the event of accidental exposure.

Please list any other chronic illness, sensitivities, accommodations or medical conditions for your camper.

My camper will need to take prescribed medications within the hours of camp

YesNo

If you answered "Yes" to the above question, it is required to fill out the table below. Note: All prescription medications must be in their original containers.

	Details
Name of Medication
Dosage Amount
Physician's Name
Physician's Phone Number
Medication Administration Time
Instructions for Use

Child Care Facility Authorization for Prescription and Non-Prescription Medication No medication shall be given by child care personnel without the signed permission of the parent or legal guardian. All medication must be in the original container with the child's name, name of the physician, medication name, and medication directions written on the label. Non-prescription medication brought in by the parent or legal guardian can only be dispensed if there is written authorization from the parent or legal guardian to do so. Medication which has expired or is no longer being administered shall be returned to the parent or legal guardian. This authorization form must be maintained and is only valid for the duration of the prescription. I hereby give permission to dispense the medication(s) listed above in accordance with the written directions on the prescription label or printed manufacturer’s label.

My Camper (2) Has Known Allergies

YesNo

Camper (2) If you answer "Yes" to the question above, please list all known allergies in the text field below. If you answer "Yes" to the question above, please list all known allergies in the text field below. Please include the severity of the allergic reaction and protocol in the event of accidental exposure.

Camper (2) Please list any other chronic illness, sensitivities, accommodations or medical conditions for your camper

My camper (2) will need to take prescribed medications within the hours of camp

YesNo

Camper(2) If you answered "Yes" to the above question, it is required to fill out the table below. **Note: All prescription medications must be in their original containers.

	Details
Name of Medication
Dosage Amount
Physician's Name
Physician's Phone Number
Medication Administration Time
Instructions for Use

Child Care Facility Authorization for Prescription and Non-Prescription Medication No medication shall be given by child care personnel without the signed permission of the parent or legal guardian. All medication must be in the original container with the child's name, name of the physician, medication name, and medication directions written on the label. Non-prescription medication brought in by the parent or legal guardian can only be dispensed if there is written authorization from the parent or legal guardian to do so. Medication which has expired or is no longer being administered shall be returned to the parent or legal guardian. This authorization form must be maintained and is only valid for the duration of the prescription. I hereby give permission to dispense the medication(s) listed above in accordance with the written directions on the prescription label or printed manufacturer’s label.

I do hereby grant my authorization and consent for SKYHOOK FITNESS INC. (hereafter "Designated Adult") to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening, I authorize the Designated Adult to summon any and all professional emergency personnel to attend, transport, and treat the minor. I agree to assume financial responsibility for all expenses of such care.

Yes, I do agree to medical treatment provided to my child outside of basic first aid.No, I do not agree to any medical treatment provided to my child outside of basic first aid

All information provided is up-to-date and accurate to my knowledge. Any changes to the information above, will be updated in writing and sent to infostaff@skyhookfitness.com

Date

Signature