Summer Camper Health & Specialized Activities Form

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*

First NameLast Name
Camper Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Current Grade for Fall 2023 through Spring 2024*
Birthdate*

MonthDayYear
Age*
Email*
Has she ever attended camp?

Day Camp1 or 2 Overnight CampWeeklong CampNo, never attended camp before
Camp Buddy Request (one only)
Custodial Care Information
My camper is under the custodial care of

Both parentsMother OnlyFather OnlyOther (name and relationship)
Custodial Care Information: Custodial Parent/Guardian #1*

First NameLast Name
Phone Number*

Area CodePhone Number
Custodial Care Information: Custodial Parent/Guardian #2

First NameLast Name
Phone Number

Area CodePhone Number
Emergency Contact #1*

First NameLast Name
Phone Number*

Area CodePhone Number
Emergency Contact #2*

First NameLast Name
Phone Number*

Area CodePhone Number
Please provide details on any information from above.

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*

First NameLast Name
Relationship to girl*
Phone Number*

Area CodePhone Number
Pick-up Adult #2

First NameLast Name
Relationship to girl
Phone Number

Area CodePhone Number
ALERT!!!! Is there anyone who IS NOT allowed to pick up your camper, please provide the information below:

First NameLast Name
Relationship to girl
What should we know about the situation?

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.*

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.*

Yes, I consentNo, 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.*

Yes, I consentNo, 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.*

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*

Summer Camper Health & Specialized Activities Form

General Camper Information

Custodial Care Information

Health Information

Camper checkout

Permissions:

Specialized Activity Permissions: