Camp COPOCO Liability Release and Waivers
These forms are required for your children to attend camp.
How many children have you registered?
*
1
2
3
4
Camper 1
First Name
Last Name
Which weeks will Camper 1 be attending? (Mark all that apply.)
*
June 29-July 2
August 10- August 14
Camper 2
First Name
Last Name
Which weeks will Camper 2 be attending? (Mark all that apply.)
*
June 29-July 2
August 10- August 14
Camper 3
First Name
Last Name
Which weeks will Camper 3 be attending? (Mark all that apply.)
*
June 29-July 2
August 10- August 14
Camper 4
First Name
Last Name
Which weeks will Camper 4 be attending? (Mark all that apply.)
*
June 29-July 2
August 10- August 14
Back
Next
Parent/Guardian Contact Info
Please list a phone number for at least one Parent/Guardian who will be the first point of contact during camp.
Parent/Guardian 1
*
First Name
Last Name
Parent/Guardian 1 Phone Number
*
-
Area Code
Phone Number
Parent/Guardian 2
First Name
Last Name
Parent/Guardian 2 Phone Number
-
Area Code
Phone Number
BACK
NEXT
Emergency Contacts/Authorized Pickup
Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age.
Emergency Contact #1
please list someone other than a parent/guardian
Full Name (non-parent)
*
First Name
Last Name
Primary Phone Number
*
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Relationship to Child
*
Emergency Contact #2
please list someone other than a parent/guardian
Full Name (non-parent)
*
First Name
Last Name
Primary Phone Number
*
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Relationship to Child
*
BACK
NEXT
Medical / Health Information
Name of Physician or Clinic/Hospital
*
Physician Phone Number
*
Format: (000) 000-0000.
Address of Physician or Clinic/Hospital
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company
*
Insurance Phone Number
*
Format: (000) 000-0000.
Insurance Group#
*
Camper 1
Camper Name
*
First Name
Last Name
Insurance ID#
*
Is the Camper up-to-date on all immunizations?
*
Yes
No
Immunization Record
Browse Files
Please upload a copy of your child's immunization record or email a copy prior to the start of camp.
Cancel
of
Has the Camper had a Physical examination in the last 12 months?
*
Yes
No
Physical
Browse Files
Please upload a copy of your child's latest Physical or letter signed by the doctor (within the past 12 months) or email a copy prior to the start of camp. Physical should include clearance to participate in school/camp and any restrictions.
Cancel
of
Does your child have any food, medication or environmental allergies?
*
Yes
No
Allergies? Check all that apply
Food
Medication
Environmental
Please list and explain any allergies
0/150
Does your child’s allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child?
Yes
No
Does your child have a special health or medical condition?
*
Yes
No
Please explain
0/150
Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during camp hours?
Yes
No
Is your child currently using any medication?
*
Yes
No
Please explain
0/150
If yes, does this medication need to be administered at the day camp?
Yes
No
Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?
*
Yes
No
Please explain
0/150
Additional Medication
Check all that apply
Prescription medication
Nonprescription medication
Refrigeration required
Topical product or lotion
Name of medication
Exact dosage
To be administered at the following times
Please provide any additional information that you think is important or may affect the camper's ability to fully participate in the camp program.
Camper 2
Camper Name
*
First Name
Last Name
Insurance ID#
*
Is the Camper up-to-date on all immunizations?
*
Yes
No
Immunization Record
Browse Files
Please upload a copy of your child's immunization record or email a copy prior to the start of camp.
Cancel
of
Has the Camper had a Physical examination in the last 12 months?
*
Yes
No
Physical
Browse Files
Please upload a copy of your child's latest Physical or letter signed by the doctor (within the past 12 months) or email a copy prior to the start of camp. Physical should include clearance to participate in school/camp and any restrictions.
Cancel
of
Does your child have any food, medication or environmental allergies?
*
Yes
No
Allergies? Check all that apply
Food
Medication
Environmental
Please list and explain any allergies
0/150
Does your child’s allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child?
Yes
No
Does your child have a special health or medical condition?
*
Yes
No
Please explain
0/150
Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during camp hours?
Yes
No
Is your child currently using any medication?
*
Yes
No
Please explain
0/150
If yes, does this medication need to be administered at the day camp?
Yes
No
Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?
*
Yes
No
Please explain
0/150
Additional Medication
Check all that apply
Prescription medication
Nonprescription medication
Refrigeration required
Topical product or lotion
Name of medication
Exact dosage
To be administered at the following times
Please provide any additional information that you think is important or may affect the camper's ability to fully participate in the camp program.
Camper 3
First Name
Last Name
Insurance ID#
*
Is the Camper up-to-date on all immunizations?
*
Yes
No
Immunization Record
Browse Files
Please upload a copy of your child's immunization record or email a copy prior to the start of camp.
Cancel
of
Has the Camper had a Physical examination in the last 12 months?
*
Yes
No
Physical
Browse Files
Please upload a copy of your child's latest Physical or letter signed by the doctor (within the past 12 months) or email a copy prior to the start of camp. Physical should include clearance to participate in school/camp and any restrictions.
Cancel
of
Does your child have any food, medication or environmental allergies?
*
Yes
No
Allergies? Check all that apply
Food
Medication
Environmental
Please list and explain any allergies
0/150
Does your child’s allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child?
Yes
No
Does your child have a special health or medical condition?
*
Yes
No
Please explain
0/150
Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during camp hours?
Yes
No
Is your child currently using any medication?
*
Yes
No
Please explain
0/150
If yes, does this medication need to be administered at the day camp?
Yes
No
Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?
*
Yes
No
Please explain
0/150
Additional Medication
Check all that apply
Prescription medication
Nonprescription medication
Refrigeration required
Topical product or lotion
Name of medication
Exact dosage
To be administered at the following times
Please provide any additional information that you think is important or may affect the camper's ability to fully participate in the camp program.
Camper 4
First Name
Last Name
Insurance ID#
*
Is the Camper up-to-date on all immunizations?
*
Yes
No
Immunization Record
Browse Files
Please upload a copy of your child's immunization record or email a copy prior to the start of camp..
Cancel
of
Has the Camper had a Physical examination in the last 12 months?
*
Yes
No
Physical
Browse Files
Please upload a copy of your child's latest Physical or letter signed by the doctor (within the past 12 months) or email a copy prior to the start of camp. Physical should include clearance to participate in school/camp and any restrictions.
Cancel
of
Does your child have any food, medication or environmental allergies?
*
Yes
No
Allergies? Check all that apply
Food
Medication
Environmental
Please list and explain any allergies
0/150
Does your child’s allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child?
Yes
No
Does your child have a special health or medical condition?
*
Yes
No
Please explain
0/150
Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during camp hours?
Yes
No
Is your child currently using any medication?
*
Yes
No
Please explain
0/150
If yes, does this medication need to be administered at the day camp?
Yes
No
Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?
*
Yes
No
Please explain
0/150
Additional Medication
Check all that apply
Prescription medication
Nonprescription medication
Refrigeration required
Topical product or lotion
Name of medication
Exact dosage
To be administered at the following times
Please provide any additional information that you think is important or may affect the camper's ability to fully participate in the camp program.
BACK
NEXT
Statement of Understanding
Sign Document
*
Name
*
First Name
Last Name
Email (for confirmation)
*
example@example.com
Date Signed
*
-
Month
-
Day
Year
Date Picker Icon
SUBMIT
Should be Empty: