Summer Camper Health & Specialized Activities Form
This is the electronic form for health, general information, and permissions to participate for your Girl Scout to attend any camp during the summer of 2024. Please complete all sections of this form so that we can give your camper the best camp experience possible, as well as, ensure that any health needs are communicated. All information provided is strictly confidential and will only be shared with necessary camp staff. This form should be completed as soon as possible. You may need your camper's vaccination records to complete this form. This form may take 20 minutes to complete.
General Camper Information
Camper Name
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First Name
Last Name
Camper Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Current Grade for Fall 2023 through Spring 2024
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Birthdate
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Month
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Day
Year
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Age
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Email
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Has she ever attended camp?
Day Camp
1 or 2 Overnight Camp
Weeklong Camp
No, never attended camp before
Camp Buddy Request (one only)
Custodial Care Information
My camper is under the custodial care of
Both parents
Mother Only
Father Only
Other (name and relationship)
Custodial Care Information: Custodial Parent/Guardian #1
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First Name
Last Name
Phone Number
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Area Code
Phone Number
Custodial Care Information: Custodial Parent/Guardian #2
First Name
Last Name
Phone Number
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Area Code
Phone Number
Emergency Contact #1
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First Name
Last Name
Phone Number
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Area Code
Phone Number
Emergency Contact #2
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First Name
Last Name
Phone Number
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Area Code
Phone Number
Please provide details on any information from above.
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Health Information
Provide comprehensive and accurate information will help us meet the needs of your camper.
Health History: Click the box for each question regarding your camper.Has or does your camper...
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no health concerns
ever had surgery/been hospitalized
had a recurring/chronic illness
had a recent infectious disease
had a recent injury
ever had a back or joint problems
have diabetes
have seizures
have headaches
have skin problems
have allergies
have fainting or dizziness
passed out or had chest pain during exercise
had mononucleosis during the past year
have problems with periods or menstruation
have trouble falling asleep or experience sleepwalking?
have asthma, wheezing, or shortness of breath
have a history of bedwetting
have problems with diarrhea or constipation
wear glasses, contacts, or protective eyewear
any other special needs such as a wheelchair, walker, has an interpreter
traveled outside the United States in the past nine months
eat a special diet
other: please see box below
Please include any information that would assist with any box checked above:
Mental, Emotional, and Social Health:Check the box if your camper has... (you may check more than one)
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No concerns
ever been treated for attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)
ever been treated for emotional or behavioral difficulties or an eating disorder
seen a professional in the last year about mental or emotional health concerns
had a significant life event that is affecting her life (such as a history of abuse, death of a loved one, family change, survived a disaster)
any fears we need to be aware of (dark, animals, etc.) or other concerns we need to be aware of, please explain below
Please include any information that would assist with any box checked above:
Immunizations
I attest that all immunizations required for school are up to date
I will need an immunization exemption form
When was the month and year of your camper's tetanus shot or booster (dT or TdaP)?
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Month
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Day
Year
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Date of camper's last physical exam:
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Month
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Day
Year
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Camper's physician
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First Name
Last Name
Physician's Phone Number
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Area Code
Phone Number
Medication: Please list all medications (including over-the-counter) or non-prescription medications the camper takes regularly. Bring enough medication in its original packaging or bottle with its prescription or over-the-counter label to last for the entire camp session. By providing the following information, you are giving permission for camp staff to administer the following:
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My camper takes NO medications
My camper takes the medications/over-the-counter medication
First Aid and Care at Camp: Under the supervision of the Health Manager, this camper may be given the following medications or generic equivalents as needed to treat an illness or injury: Acetaminophen (Tylenol), Ibuprofen (Advil), Anti-histamine (Benadryl), Anti-itch cream (hydrocortizone or calamine lotion), Antibiotic cream/ointment (Neosporin), Antacid (TUMS). If you are providing any of these types of over the counter medications as part of a daily dosage at camp, please list these above in the Medications section.
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Agree
Disagree
Is there any information about as needed, over the counter medication listed above that will assist us to best serve your camper
Additional Information: To best serve your camper, please provide information regarding any concerns/fears your camper has about attending camp. Is there anything else you would like us to know about your camper?
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Camper checkout
To ensure your camper's safety, please list the names of all those (including parents) who are authorized to pick up your camper each day of camp or on the final day of camp. Your camper will not be released to anyone who is not on the list. The person picking her up at camp or bus stop must provide a government issued ID and will be required to sign her out.
Pick-up Adult #1
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First Name
Last Name
Relationship to girl
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Phone Number
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Area Code
Phone Number
Pick-up Adult #2
First Name
Last Name
Relationship to girl
Phone Number
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Area Code
Phone Number
ALERT!!!! Is there anyone who IS NOT allowed to pick up your camper, please provide the information below:
First Name
Last Name
Relationship to girl
What should we know about the situation?
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Permissions:
Outcomes measurement: Your camper will be asked to take a short survey to measure our success in meeting Girl Scout outcomes. Your camper's opinions will be anonymous. This information is important to evaluating the Girl Scout program to make improvements and help with obtaining funding for camperships.
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I understand
Material release: I consent that photographs, artwork, audio, video, or writing of my camper (without name identification) may be used by Girl Scouts of Northern Indiana-Michiana, its assigns or successors, in whatever way they desire, including print materials, television, social media, and forms of storage, retrieval, and reproduction of the information or images; furthermore, I hereby consent that such information, photographs, videos, and the plates and/or tapes from which they are made shall be their property, and they shall have the right to duplicate, reproduce, sell, and make other uses of such information, photographs, vidoes, recordings, and plates as they may desire, free and clear of any claim whatsoever on my part.
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Yes, I consent
No, I do not consent
COVID Informed Consent Acknowledgement: I hereby attest that I have been informed of the following information pertaining to COVID-19:• COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact.• Individuals with serious underlying medical conditions are at a higher risk for severe illness.• As with any social activity, participation in in-person Girl Scouts activities could present the risk of contracting COVID-19. While Girl Scouts of Northern Indiana-Michiana (GSNI-M) takes every safety and preventative precaution, GSNI-M can in no way warrant that COVID-19 infection will not occur through participation in GSNI-M programs or troop activities. Participation may lead to exposure, illness, or quarantine requirements. I agree that:• On behalf of myself and my participating children, I will comply with the most recent guidance and recommendations issued by the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and my local state agency or municipality for slowing the transmission of COVID-19.• Neither I nor my participating children shall visit or utilize the facilities, services, and/or programs of the Girl Scout Council within 14 days after (i) returning from highly-impacted areas listed on the Indiana Department of Health and Michigan Department of Health high exposure zones, (ii) exposure to any person returning from areas subject to a CDC Level 3 Travel Health Notice, (iii) exposure to any person who has a suspected or confirmed case of COVID-19, or (iv) exposure to any other risk identified by the most recent guidelines or recommendations or situation delineated by WHO, the CDC or my state public health agency or municipality.• Neither I nor my participating children shall participate in, visit or utilize the facilities, services, and/or programs of the Girl Scout Council if I, he, or she (i) experience(s) symptoms of COVID- 19, including, without limitation, fever, cough, loss of sense of taste or smell, or shortness of breath, or (ii) has a suspected or diagnosed/confirmed case of COVID-19.
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Yes, I consent
No, I do not consent
Permissions: I give full permission for my child to attend GSNI-M summer camp and participate in all aspects of the activities and/or offsite trips. In consideration of your accepting her camp registration, I hereby, for myself, my child, my executors, and administrators, waive and release any and all rights and claims for damages I or my child may have against Girl Scouts of Northern Indiana-Michiana, their representatives, successors and assigns, for any and all injuries suffered by myself or my child at any activity sponsored by these groups.
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Yes, I consent
This Health History is correct as far as I know, and the person herein describes has permission to engage in all prescribed camp activities except as noted. Authorization for Treatment: I hereby give permission to the camp to provide routine healthcare and administer medications as indicated on Page 2 and to medical personnel selected by the camp to order x-rays, routine test, and treatment related to the health of my child for both routine healthcare and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child. I understand the information on this form will be share on a "need to know" basis and with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child's health record for providers who may treat my child, and these providers may talk with the program's staff about my child's health status. Custodial Parent/Guardian signature
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Specialized Activity Permissions:
Archery: A. Hair Protection: Participants must pull their hair back away from their face and neck. B. Clothing: Must not wear long, dangling, or overly loose clothing/jewelry. C. Protective Area: All participants will only shoot in the designated areas. D. Foot Protection: Wear closed toe shoes. Inherent Risks: Archery involves inherent risks, given the nature of the activity and the sport's precision requirements. Participants must be aware of the potential dangers, including injuries from the equipment, improper handling, and the need for focused attention during the activity.
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I consent.
I do not consent.
Bicycling/Biking: A. Clothing: Must not wear long, dangling, or overly loose clothing/jewelry. B. Hair Protection: Participants must pull their hair back away from their face and neck. C. Foot Protection: Wear closed toe shoes. D. Protective Head Gear: Participants must wear properly-fitting bike helmets. Inherent Risks: Biking involves inherent risks, given the nature of the activity and the sport's dynamic nature. Participants must be aware of the potential dangers, including falls, impact injuries, and the need for proper handling and control of the bicycle.
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I consent.
I do not consent.
Bouldering Wall: A. Clothing: Must not wear long, dangling, or overly loose clothing/jewelry. B. Hair Protection: Participants should pull their hair back away from their face and neck. C. Foot Protection: Wear closed toe shoes. D. Protective Spotters: Spotters (participants who safeguard the movements of a member of the group) provide support and protect the head and upper body of a climber in case of a fall. Inherent Risks: The Bouldering Wall involves inherent risks, given the nature of the activity and the sport's adventurous nature. Participants must be aware of the potential dangers, including falls, impact injuries, and equipment malfunctions.
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I consent.
I do not consent.
Canoeing: A. Clothing: Must wear suitable attire for canoeing, such as moisture-wicking clothing and a life jacket. B. Canoeing Areas: All participants will canoe in designated areas, progressing to other water bodies based on their skills. C. Safety: Must possess strong swimming skills in the event of a capsize. Inherent Risks: Canoeing involves inherent risks, given the nature of water activities and the sport's dynamic conditions. Participants must be aware of potential dangers, including capsizing, water-related injuries, and the need for strict adherence to safety protocols.
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I consent.
I do not consent.
Challenge Course/Ropes Course (High or low elements requiring spotting): A. Clothing: Must wear comfortable fitting pants/bottoms. B. Challenge Course/Ropes Course Areas: All participants will play in the designated areas. C. Foot Protection: Wear closed-toe shoes. Inherent Risks: Challenge Course/Ropes Course involves inherent risks, given the nature of the activity and the sport's challenging elements. Participants must be aware of the potential dangers, including falls, impact injuries, and the need for proper navigation and safety measures on the course.
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I consent.
I do not consent.
Climbing: A. Clothing: Must wear long pants for added grip and stability. B. Climbing/Ziplining Areas: All participants will only climb/zip in the designated areas. C. Foot Protection: Wear closed-toe shoes. D. Protective Head Gear: Participants must wear adventure sports helmets. E. Hair Protection: Participants must pull their hair back away from their face and neck. Inherent Risks: Climbing involves inherent risks, given the nature of the activity and the sport's adventurous nature. Participants must be aware of the potential dangers, including falls, impact injuries, and equipment malfunctions.
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I consent.
I do not consent.
Horseback Riding Agreement: A. Clothing: Must wear long pants for added grip and stability. B. Foot Protection: Wear hard-soled shoes or riding boots with heels. C. Riding Areas: All participants will ride in the ring, progressing to other areas based on their skills. D. Protective Head Gear: Participants must wear equestrian riding helmets, bearing the ASTMF emblem. Inherent Risks: Horseback riding involves inherent risks, given the nature of horses and the sport's rugged nature. Participants must be aware of the potential dangers, including falls, impact injuries, and unpredictable horse behavior.
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I consent.
I do not consent.
Kayaking: A. Clothing: Must wear suitable attire for canoeing, such as moisture-wicking clothing and a life jacket. B. Kayaking Areas: All participants will only kayak in the designated areas, progressing to other water bodies based on their skills. C. Foot Protection: Wear suitable water shoes or closed-toe sandals for foot protection. Inherent Risks: Kayaking involves inherent risks, given the nature of the activity and the sport's requirements for skill and control. Participants must be aware of potential dangers, including injuries related to kayaking, capsizing, improper paddling techniques, and the need for strict adherence to safety protocols.
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I consent.
I do not consent.
Shooting Sports (Air rifles): A. Clothing: Must not wear long, dangling, or overly loose clothing/jewelry. B. Shooting Areas: All participants will only shoot in the designated areas. C. Foot Protection: Wear closed-toe shoes. D. Hair Protection: Participants must pull their hair back away from their face and neck. Inherent Risks: Shooting sports involve inherent risks, given the nature of the activity and the sport's precision requirements. Participants must be aware of the potential dangers, including injuries related to the use of air rifles, improper handling, and the need for strict adherence to safety protocols.
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I consent.
I do not consent.
Swimming: A. Swimwear: Must not wear long, dangling, or overly loose swimwear/accessories. B. Swimming Areas: All participants will only swim in the designated areas. D. Swim Tests: Before participating at the waterfront. Anyone wanting to participate must complete a GSNI-M Swim Test. Inherent Risks: Swimming involves inherent risks, given the nature of the activity and the sport's precision requirements. Participants must be aware of the potential dangers, including injuries related to swimming, improper techniques, and the need for strict adherence to safety protocols.
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I consent.
I do not consent.
Ziplining: A. Clothing: Must wear long pants for added grip and stability. B. Ziplining Areas: All participants will only climb/zip in the designated areas. C. Foot Protection: Wear closed-toe shoes. D. Protective Head Gear: Participants must wear adventure sports helmets. E. Hair Protection: Participants must pull their hair back away from their face and neck. Inherent Risks: Ziplining Agreement involves inherent risks, given the nature of the activity and the sport's adventurous nature. Participants must be aware of the potential dangers, including falls, impact injuries, and equipment malfunctions.
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I consent.
I do not consent.
By typing my name below, I acknowledge and confirm my understanding and agreement to comply with the restrictions imposed on camp activities. I also recognize that activity availability may vary, and not all options are available at every camp. GSNI-M staff and volunteers will adhere to Safety Activity Checkpoints, follow guidelines set by the American Camp Association and state of Michigan Department of Licensing and Regulatory Affairs.
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