H2O Sports Sampler Registration
Email
*
example@example.com
I am registering for the following camp(s)
*
Sport Sampler Camp at Big Soda Lake, June 16-20
Sport Sampler Camp at Rueter-Hess Reservoir, July 14-18
Program Aid at Big Soda Lake, June 16-20
Program Aid at Rueter-Hess Reservoir, July 14-18
Camper's Information
Name
*
First Name
Last Name
Camper likes to be called? (nickname)
*
Date of Birth
*
-
Month
-
Day
Year
Date
Camper is going into grade (as of August 2024)?
*
Adult Womens' T-Shirt size
*
S
M
L
XL
XXL
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While the camper is at camp, they are in custodial care of?
*
Mother/Guardian Only
Father/Guardian Only
Both Parents
Custodial Information
Mother/Guardian Name
*
First Name
Last Name
Father/Guardian Name
*
First Name
Last Name
Custodial Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Custodial Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Indicate phone type
*
Home
Work
Mobile
Custodial Email Address
*
example@example.com
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Contact Information
A local alternate contact must be supplied (for emergency use only). No parent/guardian to be used.
Emergency Contact
*
First Name
Last Name
Relationship to Camper
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
The following Checked boxes are authorized to pick up my child from camp
*
Parent(s)/Guardian indicated only
Parent(s)/Gaurdian indicated and emergency contact
My daughter will be in a carpool and a list will be supplied
I will give you a list of Authorized People
Buddy Request - you may request one person to be in the same unit at camp.
First Name
Last Name
If your camper is a part of a carpool and/or there is a list of authorized people, please list them here.
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Health History
Do you carry Medical and/or Health Insurance for your camper?
*
Yes
No
Please upload a copy of your Insurance card (front and back). It will only be used in case of Emergency.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Date of last health exam
-
Month
-
Day
Year
Date
Were there any complicating medical problems noted?
Yes
No
If yes, please explain.
Health History: Please check any conditions you have had
Ear Infections
Diabetes
Heart Defect/Disease
Bleeding/Clotting Disorder
Hypertension
Hypotension
Seizures
Musculoskeletal Disorder
Asthma
Plant/Pollen Allergies
Insect Sting Allergy
Drug Allergies (specify)
Other Allergies (specify)
German Measles
Mumps
Chicken Pox
Please explain health conditions checked above
Other health conditions
Constipation
Menstrual Cramps
Motion Sickness
Sleep Disturbances
Special dietary regimen
Emotional disturbances
Fainting
Nosebleeds
Hearing Impairment
Wear Glasses
Wear Contact Lenses
Sickle cell trait or disease
None
Other
Please explain other health conditions checked above. Indicate any information useful to the adult in charge in relation to any of these health conditions. Also, indicate any activities to be encouraged or restricted.
Are there other health concerns the Health Supervisor/Camp Directors should be aware of?
Yes
No
If Yes, please explain health concerns Health Supervisor/Camp Directors should be aware of.
Immunization History
D.T.P. (diptheria; Pertussis (whooping cough); Tetanus)
Year primary series completed
Year of last booster
TD
Year primary series completed
Year of last booster
Measles
Year primary series completed
Year of last booster
Mumps
Year primary series completed
Year of last booster
Rubella (German Measels)
Year primary series completed
Year of last booster
Oral Polio
Year primary series completed
Year of last booster
HIB
Year primary series completed
Year of last booster
Teburculin Test (Most Recent)
Result
Date of Last Tetanus Booster
-
Month
-
Day
Year
Date
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Are you taking any medication?
Yes
No
If Yes, please list medications you are taking.
Since your last exam, have you had
A serious injury requiring medical attention?
Treatment in a hospital or emergency room?
An illness lasting more than five (5) days?
A surgical operation or fracture?
Any restrictions concerning physical activities?
None of the above.
Other
Give dates and explain any of the above checked
Do you consider yourself to be in good health and able to participate in normal program activities?
Yes
No
If no, please explain
Dietary considerations
Are you vaccinated against Covid 19
Yes
No
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Signatures
Please check here to confirm that you have read, understood and agree to the terms.
To the best of my knowledge, this health history is correct.
To the best of my knowledge, this health history is correct.
In case of emergency, I give my permission to persons representing Girl Scouts of Colorado to see that I receive appropriate emergency medical or surgical treatment, and/or hospitalization if necessary. It is understood that every effort will be made to reach the person named above as my emergency contact.
I consent that my camper's name, image, and likeness, as shown in the video-tapes, photographs, motion picture film and/or electronic images for which she posed, and/or audio recordings made of her voice may be used by Girl Scouts of the U.S.A., its assigns or successors, in whatever way they desire, including television and Web sites; furthermore, I hereby consent that such photographs, films, recordings, electronic images, and the plates, tapes and/or software from which they are made shall be their sole property, and they shall have the right to sell, duplicate, reproduce and make other uses of such photographs, films, recordings, electronic images, plates, tapes and software as they may desire free and clear of any claim whatsoever on my part.
I DO NOT consent that my camper's name, image, and likeness, as shown in the video-tapes, photographs, motion picture film and/or electronic images for which she posed, and/or audio recordings made of her voice may be used by Girl Scouts of the U.S.A., its assigns or successors, in whatever way they desire, including television and Web sites; furthermore, I hereby consent that such photographs, films, recordings, electronic images, and the plates, tapes and/or software from which they are made shall be their sole property, and they shall have the right to sell, duplicate, reproduce and make other uses of such photographs, films, recordings, electronic images, plates, tapes and software as they may desire free and clear of any claim whatsoever on my part.
I consent, that my name, image, and likeness, as shown in the videotapes, photographs, motion picture film and/or electronic images in which I appear, and/or audio recording made of my voice may be used by Girl Scouts of the U.S.A., its assignor successors, in whatever way they desire, including television and Web sites; furthermore, I hereby consent that such photographs, films, recordings, and electronic images and the plates, tapes and/or software from which they are made shall be their sole property, and they shall have the right to sell, duplicate, reproduce and make other uses of such photographs, films, recordings, electronic images, plates, tapes and software as they may desire free and clear of any claim whatsoever on my part,
I DO NOT consent, that my name, image, and likeness, as shown in the videotapes, photographs, motion picture film and/or electronic images in which I appear, and/or audio recording made of my voice may be used by Girl Scouts of the U.S.A., its assignor successors, in whatever way they desire, including television and Web sites; furthermore, I hereby consent that such photographs, films, recordings, and electronic images and the plates, tapes and/or software from which they are made shall be their sole property, and they shall have the right to sell, duplicate, reproduce and make other uses of such photographs, films, recordings, electronic images, plates, tapes and software as they may desire free and clear of any claim whatsoever on my part,
Signature to indicate you agree to the terms and conditions.
Date Signed
Submit
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