If you'd like to add a second parent, please include all information that is different from above.
These must be people with a different phone number from the parents/guardians and in Michigan during camp.
In some instances it may be helpful for the cabin counselors or other staff members to know some of the information on the medical record. By checking yes, we will still keep information as confidential as possible.
Please check one of the options below.
At the end of each week of camp, we like to give out a list of all participants. The list includes name, parish, cabin, and a way to contact them. Please put the best contact information below (email address or phone number - or "none" if you wish not to have that listed).
AllergiesPlease let us know if your child has any allergies, and what the reaction is.If the reaction is serious, please make sure you send the needed medication.
Special food needsNote any food your child won't or can't eat.Is your child a vegetarian, or doesn't eat cheese or dairy? If so, please let us know so we can tell the kitchen staff and make sure there are great food for your child to eat!
Special physical and emotional informationKeeping in mind that we live together for 24 hours a day, for 6 days, please tell us about any physical, emotional, or mental health information that will help us make sure your child has a wonderful week at camp. Things like depression, homesickness, and bedwetting can be listed here.
Any other helpful informationPlease include any additional information. Explanations about any of the above matters, along with hints like He loves to read, or She loves to swim sure helps us!
Bring enough medication to last the entire time at camp. Keep it in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration.
All campers must be signed out at the end of each session.
Because we encourage carpooling, we allow campers to be released to adults who are not their parents. If there is someone your child MAY NOT be released to, please list the name(s) below.
If there is someone who is legally not allowed to have contact with your child, please alert the Camp Director.
Early or mid-session ReleaseWe know that sometimes campers need to leave a bit early, or even mid-session and return. Please help us plan by listing the dates/times below, and letting the cabin counselor know.
As a parent/guardian, I hereby give permission for the designated child to attend the Episcopal Youth Camp in the Diocese of Western Michigan and to participate in all the activities except as noted above and give permission for my child to be transported in cases of emergency or for a planned program. I understand that my child must follow the rules set forth by the Diocese of Western Michigan. If dismissal because of a disciplinary problem occurs, transportation will be provided by or paid by the person or a parent and any registration fees will not be reimbursed. A copy of the incident report and the course of action will be kept in the camp files, be sent to the person’s home rector or sponsoring clergy person and be sent to the Bishop.
This health history is correct and complete as far as I know. I give permission to the camp to provide routine health care, administer medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. I give permission to the camp to arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician/nurse selected by the camp to secure and administer treatment, including hospitalization, for the person named above. Information in this completed form may be printed and photocopied as necessary.
I agree to hold the Diocese of Western Michigan and any associated agencies and persons harmless and waive any claims for payment of accident, injury, disability or damages to the person or property of the aforementioned child arising out of or connected with his/her participation in any activity related to his/her participation in the aforementioned activity.