Parent Information Continued
Authorized Pick Up List
(Please Note: The person must be 18 years or older with a valid picture ID in order for the child to be released)
Guided Grace FYS Enrichment and Mindfulness camp is dedicated to your child’s overall wellbeing and success with this program. In order to ensure that this happens we need support and encouragement from you. Please understand that success begins with your support. We ask that your child participate daily and if they are unable to come please contact your site manager. In addition to that, please commit to completing surveys as they are sent. This helps us better serve your family.
After School / Sumer Camp
School Age Immunization Waiver
By signing this waiver you are affirming that your child has been immunized in accordance with DHHS & Saginaw County Health Department guidelines and attest that your child's shots are current and on file with their school.
After School / Sumer Camp
Permission to Photograph
I agree and give legal consent that photos/videos taken of my child(ren) during camp activities on any given camp day can be legally used in agency specific publications, publicity, illustrations, copyright purposes, and advertising . I also agree and legally consent to the use of photos/videos the corporate website for marketing and educational purposes. Furthermore, I understand that no royalty or compensation shall become payable to me by reason of such use.
Summer Camp Medical Form
Additional contact in the event that the parents/guardians can’t be reached
(Please describe the allergy, whether the allergy is caused by ingestion, touch or airborne and what the level of allergy is (mild, severe or anaphylactic)
Camper Health History– Please circle the as appropriate
Medical Insurance Information
Camper Medications– Please list any medications the camper is currently taking and dosage:
What else should we know? Please provide any additional information that would be helpful for staff to know for your camper
to have a successful week.
Parent/ Guardian Authorization for Health Care
The Participant’s medical conditions and information stated on this application is complete and correct. I give
permission to the Severson Dells staff to (1) provide appropriate first aid for minor injuries; and (2) seek further
treatment from local physicians or hospitals if the medical condition warrants. In the event I cannot be reached in an
emergency, I also give permission to the treating physician to examine, diagnose, and treat or secure proper
treatment for the Participant and hospitalize, and to order injection and/or anesthesia and/or surgery for the
Participant, as the physician shall determine proper and necessary under the circumstances. I agree to assume f ull
financial responsibility for the costs of any evacuation and/or medical treatment that the Participant may receive. A
photocopy of this consent shall be as valid and may be accepted as the original.
I certify that I have completed all sections of this Health Form and accept full responsibility for any errors or omissions.
The Participant has permission to take part in all program activities except as noted above. I understand the
information on this form will be shared on a “need to know” basis with Severson Dells staff.
I fully understand that the Participant is to abide by all rules governing personal conduct during all activities. Any
violation of these rules may result in the Participant being sent home at the expense of his/her parent/guardian. I
understand that no refunds will be given for Participants sent home due to disciplinary procedures or illness and that
it is my responsibility to pick up a Participant sent home for such a reason.