Clone of DRAFT: Summer Camp Paperwork 2026

Before You Begin

If you are completing this form on a smartphone, please turn your device to landscape (horizontal) orientation to ensure all required fields are visible.

To complete this form, please have the following information ready:
- Emergency contact information
- Your child's immunization records
- Credit or debit card details
- Medication information, if applicable (including any prescription or over-the-counter medications, EpiPens, or inhalers your child may need at camp)
We would like to thank Walmart for generously sponsoring our new online paperwork platform, Jotform. Their support helps us streamline forms and improve the experience for our camp families.

Family Information Form

Used to record parent/guardian information, emergency contacts, and individuals authorized for pick-up.
Parent/Guardian #1

First NameLast Name
Authorized Pick-Up

YesNo
Email
example@example.com
Phone Number (Cell)

Area CodePhone Number
Staff can contact you via (preference)

Text MessagePhone CallBoth
Place of Employment:
Phone Number (Work)

Area CodePhone Number
Emergency Contacts

Please list emergency contacts in the order in which they should be contacted in case of emergency.
Emergency Contact #1

First NameLast Name
Relationship to Child
Phone Number

Area CodePhone Number
Authorized Pick-Up

YesNo
Authorized Pick-Ups

Please list any additional individuals authorized to pick-up the child from camp besides those indicated above.
Name

First NameLast Name
Relationship to Child
Phone Number

Area CodePhone Number
Would you like to list additional authorized pick-up individuals?

YesNo
Name

First NameLast Name
Relationship to Child
Phone Number

Area CodePhone Number
Name

First NameLast Name
Relationship to Child
Phone Number

Area CodePhone Number

General Child Information

Please answer the questions below to help our staff get to know your child. If this is your child’s first year in the Village of Bellevue Summer Camp program, we recommend completing this section so our staff can better prepare and provide the best possible camp experience.
Has your child attended the Village of Bellevue's Summer Camp program prior to this year?

Yes, my child is a returning camper.No, my child is a new camper.
My child's strengths are:
Ex: "My child enjoys helping others."
My child's weaknesses are:
Ex: "My child becomes frustrated when playing with others."
My child's interests are:
My child's dislikes are:
Any other information you would like to staff to know:
Child Accomodations

We ask parents if their child has an IEP or 504 Plan so our camp staff can better understand how to support each camper’s needs. Sharing this information is completely optional. However, if you feel that providing your child’s accommodations would help us create a more successful and comfortable camp experience for them, you are welcome to do so.
Does your child have an active IEP or 504 plan?

YesNoPrefer not to answer
If yes, would you be open to sharing it with us to help our staff provide the best support for your child during camp?

Yes, I will upload a copy or summary of the accommodations.Yes, but I'd prefer to talk with staff directly.No, I prefer not to share at this time.
Upload IEP or 504 Plan summary (accommodations/supports only):

Browse Files
Optional Cancelof

Child Health Information

To help camp staff support your child’s safety and well-being. Your information is securely protected and HIPAA compliant.
Child Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Healthcare Information
Does your child have a history of:
Please list your child's allergies (if applicable):
Please describe any health conditions checked above:
Triggers that may cause problems:
Signs or symptoms to watch for:
Action steps for staff to take:
When to call parent/guardian regarding symptoms or failure to respond to treatments:
When to consider emergency care for child's medical condition:
Sunscreen & Insect Repellent Policies
Parent/Guardian Signature

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By signing above, you understand the sunscreen and insect repellent policies checked above.

Medication Authorization Form

Required authorization for camp staff to administer medication when necessary.
Medication Requirements:
- Prescription medications must be in the original container with the pharmacist's label marked with the prescription number, date, child's name, and physician's name.
- All non-prescription medications (OTC's) must be labeled with child's name.
- Please give all medications to camp staff upon arrival at the beginning of the week your child will be attending camp.
- All remaining medication will be returned to a parent/guardian at the end of each week. If medication is not picked-up, the Village of Bellevue will dispose of medication in an environmentally safe manner.
- If your child brings an inhaler or EpiPen to camp for emergency use, consent must be given via this form.
Is this form applicable to your child?

YesNo
Child's Name

First NameLast Name
Authorization is effective from
Name of Medication
NOTE: MEDICATION MUST BE IN ORIGINAL CONTAINER
Instructions for Administration
Include dosage and frequency of medication administration
Please select to list additional medications

Select for more
Name of Medication
NOTE: MEDICATION MUST BE IN ORIGINAL CONTAINER
Instructions for Administration
Include dosage and frequency of medication administration
Parent/Guardian Signature

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Date

MonthDayYear
Today's Date

Immunization History

The following are the minimum required immunizations. Children entering kindergarten must have received one dose of DTP/DTaP/DT after their 4th birthday to be compliant. Measles, mumps, and rubella vaccines must have been received on or after the 1st birthday.
If your child is unvaccinated, please indicate below:

This child is not immunized for religious reasons.This child is not immunized for personal conviction reasons.
How would you prefer to submit your child's immunization records?

Attach a digital copy to this formList the dates your child received each immunization dose
Attach immunization records

Browse Files

Cancelof
DTP/DTaP/Td (Whooping Cough)
Polio
Haemophilus Influenzae (HIB)
Hepatitis B
Measles, Mumps, Rubella (MMR)
Varicella (Chicken Pox)
Parent/Guardian Signature

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By signing you are authorizing that all information provided on this form is accurate to the best of your knowledge.
Date

MonthDayYear
Today's Date

Credit/Debit Card Draft Agreement

Submission of this Payment Authorization Form is required for all camp families in order for a child to attend Summer Camp 2026.

Your completed authorization must be submitted no later than May 1, 2026 by either:
- Printing the attached PDF, completing it, and dropping it off at the Village Offices (3100 Eaton Road, Bellevue, WI, 54311)
OR
- Call the Village Offices to provide your card information by phone (920) 468-5225
Do not scan, upload, or email this form.

If this financial information is not submitted before your child’s first week of camp, your child will not be permitted to attend, even though your camp spot will be held and full weekly camp fees will still be charged.

This authorization must be received by the Village Offices before your child’s first day of camp in order for your child to participate.
Select how you will submit your payment authorization form:*

Print and drop off at the Village OfficesCall the Village Offices with my card information
Payee Signature

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I agree to submit the Payment Authorization Form using the method selected above no later than May 1, 2026.

Summer Camp Field Trip Permission Form

To be used to inform staff of registered field trips for camper.
I give my child, First Name Last Name, permission to attend the following field trip(s) checked below.
Date & Field Trip Location
Parent/Guardian Signature

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Media Release Form (Optional)

Allows the Village of Bellevue to use your child’s photo or video for promotional or informational materials.
Please list each child individually
Parent/Guardian Signature

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I release the Village of Bellevue from all claims & confirm that I am at least 18 years old and legally competent to agree to this on behalf of the minor(s) listed below.
Should be Empty:

	Location	Before Care	After Care	Field Trip	On Waitlist	Enrolled
Week #1 Jun 8-12
Week #2 Jun 15-19
Week #3 Jun 22-26
Week #4 Jul 6-10
Week #5 Jul 13-17
Week #6 Jul 20-24
Week #7 Jul 27-31
Week #8 Aug 3-7
Week #9 Aug 10-14
Week #10 Aug 17-21 DEBROUX ONLY

Before You Begin

Family Registration Form

Family Information Form

Emergency Contacts

Authorized Pick-Ups

General Child Information

Child Accomodations

Child Health Information

Sunscreen & Insect Repellent Policies

Medication Authorization Form

Medication Requirements:

Immunization History

Credit/Debit Card Draft Agreement

Summer Camp Field Trip Permission Form

Alternate Arrival/Release Agreement

Arrival Instructions

Release Instructions

Media Release Form (Optional)