Hopewood Consent Form fillable

HopeWood Connect & Amazing Grace Day Camps Registration, Health, & Permission

Please print legibly. Parent or guardian is to complete this form in pen. Thank you.

Camper Name

First NameLast Name

Street Address (or P.O. Box)

City

State

Zip

Gender

Grade Completed

Birthdate

Date

T-Shirt Size (Applicable for Congregation Use):

YS YM YL AS AM AL

Home Church

City

Pastor

Parent/Guardian Information

First & Last Name

Home Phone Number

Cell Phone Number

E-Mail

example@example.com

Additional Parent/Guardian First & Last Name

Home Phone Number

Cell Phone Number

E-Mail

example@example.com

Additional Emergency Contact Information: If the parents or guardians are not available in an emergency, notify

Phone/cell

Name

Phone/Cell

During Day Camp, how will your child come and leave from the day camp site? (please indicate below: walk, bike, car - or whatever combination

The following person(s) is/are permitted to pick up my child from Day Camp

2.

3

DO NOT release my child to the following person(s):

1

2.

Camper’s Doctor

Phone

Camper’s Dentist

Phone

Health Insurance Company

Policy Holder’s Name

Policy Group Numbers

Policy Number

List any disability or recurring illness

Note any activities to be limited

Specify any dietary concerns or limitations

Include current medication or medical treatment

Name and Dosage

Note: All medications sent to camp must be in the original containers and given to the Church Coordinator.

Note all allergies: Bee Stings Aspirin Penicillin Peanuts Other

Immunization Record: Check (with an X) if current:

DPT Series

Mumps

Measles

Rubella

Polio Series

Hepatitis B Series

TB Test Result

Date of Tetanus Booster

Date

Date of COVID-19 Vaccination

Date

Please provide any other information or restrictions that might help the day camp staff and volunteers to know how best to care for your child (behavioral, physical, emotional, mental health):

Release: I hereby give permission for the camper, previously named, to participate in all day camp activities and off-site field trips, except as previously noted. I also consent to the use of any photograph or video recordings of my child or family in future HopeWood Outdoors or ELCA publications.

I understand that every effort will be made to contact me if my child needs emergency medical-surgical treatment. But if it is important to do so, I hereby give my permission to the physician selected by the Camp Staff to secure proper treatment, to hospitalize, to order injection, anesthesia, x-ray or surgery for my child as named above. I further authorize the Church Coordinator, or their designee, to administer over the counter drugs and medications as needed.

Date

Printed Name

Parent/Guardian Signature

FOR CHURCH COORDINATOR USE (Hopewood Day Camps) - Fees per person for week of Day Camp; Amount received and Date; Balanace