Straight Arrow Clubs & Camps, Inc.

Camper Name:*

First NameLast Name

Preferred Name:

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

School Grade:*

Date of Birth:*

Date

Gender:*

MaleFemale

Parent/Guardian Name:*

First NameLast Name

Phone Number:*

Please enter a valid phone number.

Campers must carry medical insurance and/or be responsible for medical expenses in case of an emergency.

Insurance Information:

Insurance Company Name:*

Policy #:*

Phone Number:*

Please enter a valid phone number.

Insured's Name:*

First NameLast Name

Relationship to Camper:*

In case of emergency, (other than parent)

Alternate Contact:*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Dietary Restrictions:*

YesNo

If yes, please list

List any allergies or other physical restrictions or health issues below

Is Camper taking any medications?*

YesNo

If yes, please list the medication, dosage to administer, and time to be administered each day.

I authorize Camp Personnel to administer the following medications to my camper, as needed. (Select all that apply)

Acetaminophen (Tylenol)Benadryl (Allergy medication)IbuprofenCough drops/syrup

We are State Regulated. All medicine must be turned in during registration and will be administered by an authorized Camp personnel at the appropriate time. All medication will be stored in the Main Lodge (Hogan) in a locked cabinet at all times. Please be sure all medication is clearly marked with the camper’s name and dosage to be given.

Date of last DPT Immunization*

Date

Date of last MRR Immunization*

Date

Date of last Varicella Immunization*

Date

My Camper has been vaccinated for COVID-19:*

YesNo

In case of an emergency, a representative of Straight Arrow Clubs and Camps, Inc. will seek the assistance of a qualified doctor, dentist, or emergency personnel, at your expense. Please sign below to indicate your acceptance of this policy.

BE AWARE: Straight Arrow Camp is located on 55 acres of wooded land. There are ants, ticks, bee’s, flying bugs, mosquitos, snakes, various other bugs, raccoons, dogs and armadillo. There are stickers and poison ivy. We have certain peanut products. You should be physically and mentally fit to handle heat and humidity and the various bugs. If you have allergies, be aware and bring appropriate medication to offset this.

The undersigned as the parent/guardian(s) of Camper name* do hereby consent to any and all medical/surgical treatment, anesthesia, or operations, which may be deemed advisable by any qualified doctor. The intention hereof is to grant authority to administer and to perform singularly any examinations, treatment, anesthetics, operations and diagnostic procedures that may be now, during the course of the patient’s care, deemed advisable or necessary by any qualified medical doctor.

I further agree to hold Straight Arrow Clubs & Camps, Inc. and their representatives harmless for any liability to my child because of any claims on behalf of my child against the agents because of any injury or alleged injury to my child resulting from negligence of others. If legal action should, for any reason, be taken against these agents, on behalf of my child, and the agents not be found at fault, I agree to pay any attorney fees, court fees, damages, or other costs they may incur to defend itself against such action.

Signature of Parent or Legal Guardian

Print Name of Parent or Legal Guardian

Straight Arrow Clubs & Camps, Inc.

Camper Information

Parent(s)/Guardian(s) with whom child is living:

Medical Information

Information for Counselors