Registration Form
Additional documents for registration to be brought in on the first day of camp: A copy of the Immunization Record. A Copy of a Physical within the last 12 months. Please fill out the registration form in its entirety to ensure your child starts on time. Leaving information off could result in a late start for your child.
FAMILY INFORMATION
Father/Guardian's Name(Leave blank if not applicable)
First Name
Last Name
Father/Guardian's contact number(Leave blank if not applicable).
Please enter a valid phone number.
Father/Guardian's Work phone number(Leave blank if not applicable).
Please enter a valid phone number.
Father/Guardian's Email (Leave blank if not applicable).
example@example.com
Father/Guardian's Address(If different from the child)(Leave blank if not applicable).
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother/Guardian's Name(Leave blank if not applicable).
First Name
Last Name
Mother/Guardian's contact number(Leave blank if not applicable).
Please enter a valid phone number.
Mother/Guardian's work number(Leave blank if not applicable).
Please enter a valid phone number.
Mother/Guardian's email (Leave blank if not applicable).
example@example.com
Mother/Guardian's Address(If different from the child)(Leave blank if not applicable).
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CONTACTS
Your child will be released only to the parents/guardians listed above. The child can also be released to the following individuals listed below, as authorized by the person who signs this application. In the event of an emergency, if the parents/guardians cannot be reached, the facility has permission to contact the following individuals. Please List at least 3. Pick up person #1 (Name and number).
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Pick up person #2 (Name and number).
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Pick up person #3 (Name and number).
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CHILD'S INFORMATION:
Child's Name
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First Name
Last Name
Gender
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Male
Female
Child's Age
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Child's Birthday
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HEALTH CARE NEEDS:
If your child has any healthcare needs such as allergies, asthma or other chronic conditions that require specialized health services, it's crucial to provide a medical action plan to the Nehemiah Camp. This plan should be completed by either the child's parent or healthcare professional. However, if your child requires in-depth medical attention, it's important to discuss this further with the Nehemiah Camp Director. Ensuring that your child's medical needs are met is of utmost importance and we strive to create a safe and healthy environment for all campers.
Child's Insurance Information( ID number and or Group Number).
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Does your child require a medical action plan? If yes, please ensure that you provide a medical action plan for your child's healthcare needs on the first day of camp if required. This plan should be updated annually and whenever changes occur. Our priority is to ensure that all campers' medical requirements are met, and we are committed to creating a safe and healthy environment for everyone.
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Yes
No
Not Applicable
List any allergies and the symptoms and type of response required for allergic reactions.
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List any health care needs or concerns, symptoms of and type of response for these health care needs or concerns.
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Is your child up to date on all immunizations? If not, before your child starts at our camp, we kindly ask that you ensure they are up to date on all their immunizations. Please note that your child must have all necessary immunizations administered within 30 days from the start date of camp, and we will require a copy of their immunization record. This is to help us maintain a safe and healthy environment for all campers.
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Yes
No
Has your child had a physical within the last 12 months? If not, it is necessary for them to have one within 30 days from the start of the camp to ensure a safe environment.
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Yes
No
EMERGENCY MEDICAL CARE INFORMATION:
Name, Number, and Address of the child's Physician.
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List any types of medication taken for health care needs.
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I, as the parent/guardian, authorize the Nehemiah Camp to obtain medical attention for my child in an emergency. Signature of Parent/Guardian(sign and date).
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Date
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Month
-
Day
Year
Date
I, as the operator, do agree to provide transportation to an appropriate medical resource in the event of an emergency. In an emergency situation, other children in the facility will be supervised by a responsible adult. I will not administer any drug or any medication without specific instructions from the physician or the child’s parent, guardian, or full-time custodian. Signature of Administrator (LEAVE BLANK FOR THE CAMP'S ADMINISTRATOR)
List any particular fears or unique behavior characteristics the child has.
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Share any other information that has a direct bearing on assuring safe medical treatment for your child.
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Does your child have any learning barriers? If so, please list them so we are able to better assist them.
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CHILD'S INFORMATION CONTINUED
What are your child's likes and Dislikes?
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Do you give permission for your child to ride on the Nehemiah Camp van for field trips into the community?
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Yes
No
If you answered yes or no to the question above, please sign below giving or declining permission for your child to ride the Nehemiah Camp van.
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Please indicate whether you grant or deny the consent for the Nehemiah Camp staff to photograph and/or video record your child for online publications by choosing either yes or no.
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Yes
No
Please sign your name below to indicate whether you granted or denied the consent for Nehemiah Camp staff to photograph and/or video record your child for online publications. Thank you for your cooperation.
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Is your child fully Potty trained? If not, please ensure that you pack two additional sets of clothing including tops, bottoms, underwear, and socks. This will ensure that they have everything they need in case of any accidents.
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Yes
No
Please be aware that Nehemiah Camp is not responsible for any lost or stolen items my child may bring. Electronics are only allowed with permission from camp staff on specific days.
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We understand that the safety of your child is of utmost importance to you, and it is to us as well. Our team is dedicated to ensuring that your child is always safe and secure while in our care. In the unlikely event of an accident or incident, we will inform you promptly and provide a detailed explanation of what took place.
I acknowledge that I have read, understood, and agree to all the questions and statements mentioned above. I confirm that I am providing accurate information to the best of my knowledge.
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Date
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Month
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Day
Year
Date
Submit
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