Camp Registration Form

Camp Registration Form

These forms are required for your children to attend camp.
Camper's Information
Camper Name*
Date of Birth*

MonthDayYear
Age
Camper Swimming Ability*

Non-SwimmerLimited AbilitySwimmer

Parents' Information

Parent/Guardian 1
Parent/Guardian 1*

First NameLast Name
E-mail*
Cell Phone*
Home Phone
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 2
Parent/Guardian 2

First NameLast Name
Relationship to Child
E-mail
Cell Phone
Home Phone
Home Address Same as Parent/Guardian 1?

Yes
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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.
Emergency Contact #1
Full Name*

First NameLast Name
Primary Phone Number*
Emergency Contact #2
Full Name

First NameLast Name
Primary Phone Number

Medical / Health Information
Name of Physician*
Phone Number*
Does your child have any food, medication or environmental allergies?*

YesNo
Please list and explain any allergies or dietary restrictions*

0/150
List Past medical treatments/hospitalizations
Does your child have a special health or medical condition? (physical, mental, psychological)*

YesNo
Please explain*

0/150
List dates of last immunizations*

0/150
List current prescribed and over-the-counter medications*

0/150
List activity limitations because of health
Medical Transportation Statement

I, participant, parent, or legal guardians of participant, authorize the transportation of participant for medical treatment. I further understand that I shall be responsible for any and all costs associated with the transportation of participant. Finally, I authorize medical treatment for the participant, at my cost, if the need arises.
Signature of Parent/Guardian and Date*

Clear

Statement of Release (for publications)
I hereby grant Jupiter Outdoor Center permission to take and/or use photographs and/or statements of my child(ren) and me for promotional purposes, i.e. brochures, fliers, presentations, etc. In connection therewith, I release and hold Jupiter Outdoor Center and their agents, servants or employees harmless from any and all claims and causes of action for circumstances resulting from use of any photograph and/or statements.
Signature of Parent/Guardian and Date

Clear
Release and Indemnity Agreement

In consideration of the acceptance of my participation and/or the participation of my child or ward in all summer camp activities sponsored by Jupiter Outdoor Center, and with the understanding that such activities have inherent risks, hazards and dangers for anyone, I agree to assume the risks incident to such participation and, on my own behalf, and on behalf of my child or ward, and on behalf of my child’s or ward’s heirs, executors and administrators, release and forever discharge Jupiter Outdoor Center and its agents, designees, employees, officers, and officials, of and from all liabilities, claims, actions, damages, costs or expenses of any nature, arising out of or in any way connected with my participation and/or the participation of my child or ward in such camp activities and further agree to indemnify and hold the released parties harmless against any and all such liabilities, claims, actions, damages, costs or expenses, including, but not limited to, attorney’s fees and disbursements. I understand this release and indemnity agreement includes any claims based on the negligence, actions or inaction of Jupiter Outdoor Center, Inc. and its agents, designees, employees, officers, and officials, and covers death, bodily injury and property damage, whether suffered by me, my child or ward before, during, or after such participation.
Signature of Parent/Guardian and Date*

Clear
First Aid & Medications

Counselors trained and certified in First Aid/CPR will be with the camp group at all times, as well as fully supplied first aid kits. The scope and authority of our immediate camp staff is limited to basic lifesaving practices, first-aid and CPR, any incidents beyond that scope will be referred to emergency medical services. For all injuries/illness incurred at camp, that JOC Camp Staff is made aware of, including minor injuries/illnesses, a camper’s parent/guardian will be notified of that injury/illness. Depending on the severity of the incident, the camper’s parent or guardian may be called, while minor scrapes and injuries may be communicated at the time of camper pick up. Any incidents requiring emergency services be called to respond, the parent/guardian will be contacted as rapidly as possible.

It is the policy of the Jupiter Outdoor Center that our camp staff WILL NOT ADMINISTER prescription medications to camp participants (campers). Over-the-counter medications, unless a specific need arises while performing first-aid, will also not be administered by JOC staff. If a camper(s) requires medication, it is recommended that medication be administered by their parent or legal guardian prior to the beginning of camp and/or after the camp program has ended.
Authorization for the Application of Sunscreen, Insect Repellant, and Basic First Aid
My child is allowed to receive basic first aid if needed, and the following (please check all that apply):*

SunscreenBug SprayWhite Vinegar (jellyfish & sea lice stings)NONE
Print Parent/Guardian Name*
Parent/Guardian Signature and Date*

Clear
Signature of Witness (JOC Employee)

Clear
*This signature must be witnessed by an employee of Jupiter Outdoor Center.

If you have any questions, please call the JOC at 561-747-0063.
How did you find out about us?
TERMS OF SERVICE & REFUND POLICY:

If Jupiter Outdoor Center cancels a day or week of camp due to dangerous weather conditions, or other conditions beyond its control, you will receive 100% credit towards another camp day or camp week. Any portion of less than one camp session is not refundable if weather causes early cancellation of camp. Should you choose not to attend or are unable to attend due to medical condition or for any reason you may get up to a 50% credit towards a future day or week of camp if you cancel in writing by email to jupiteroutdoorcenter@gmail.com at least 48 hours prior to the camp day or week. There is no refund or credit if you do not attend camp or your child is unable to attend. Missed days of camp cannot be rescheduled for any reason.
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Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Camp Registration Form

Camper's Information

Parents' Information

Emergency Contacts/Authorized Pickup

Medical / Health Information

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