After School/Summer Camp Enrollment Form

Child Information

Site selection(Required)

Child’s Name:(Required)

First Last

Gender:(Required)

Male

Female

Date of Birth:(Required)

Child’s Address:(Required)

Street Address City ZIP / Postal Code

School District:(Required)

Child’s Ethnicity:(Required)

African American

White

Hispanic/Latino

Other

Parent Information

Parent Name:(Required)

Phone Number -Cell:(Required)

Phone Number -Home:(Required)

Are you able to receive text (SMS) messages ?(Required)

Yes

Driver license?(Required)

Yes

Upload driver license

Max. file size: 256 MB.

Email Address:(Required)

Parent Information Continued

Emergency Contacts

Name:(Required)

Relationship to child:(Required)

Address:

Street Address City ZIP / Postal Code

Home Phone:(Required)

Cell:(Required)

Is this person authorized to pick your child up from camp?(Required)

Yes

Name:

Relationship to child:

Address:

Street Address City ZIP Code

Home Phone:(Required)

Cell:(Required)

Is this person authorized to pick your child up from camp?(Required)

Yes

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)

Name:

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.

Date

Name of Child

Age

Name of Parent or Legal Guardian

Signature

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.

Child’s Name:

Parent/ Legal Guardian Name:

Parent/Legal Guardian Signature:

Date

Phone Number:

Summer Camp Medical Form

Camper Name(Required)

Birthday:(mm/DD/YY)(Required)

Camp Session(Required)

Parent/Guardian 1:(Required)

Relationship to camper(Required)

Preferred Phones(Required)

Parent/Guardian 1

Relationship to camper

Preferred Phones(Required)

Additional contact in the event that the parents/guardians can’t be reached

Name(Required)

Relationship to camper(Required)

Preferred Phones(Required)

Preferred Phones

Allergies(Required)

No known allergies

This camper is allergic to:(Required)

Food

Medications

Environmental (bee stings, hay fever, etc.)

(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)

Does the camper use an inhaler:

Yes

If so, what kind:

Does the camper carry an epi-pen:

Yes

Camper Health History– Please circle the as appropriate

Has the participant ever had bleeding/ clotting disorders?

Yes

Does the participant have a seizure disorder?

Yes

Does the participant have any physical impairments?

Yes

Does the participant have diabetes?

Yes

Does the participant have asthma?

Yes

Does the participant have vision impairments?

Yes

Does the participant have headaches?

Yes

Does the participant wear glasses, contacts or protective eyewear?

Yes

Has the participant been treated for ADD/ ADHD?

Yes

Does the participant have problems with fainting or dizziness?

Yes

Activity Restrictions : Does the camper have any restrictions to participating in activities, be it physical, mental or behavioral?

Yes

If so, please explain restriction or adaptation needed:

Medical Insurance Information

This camper is covered by health insurance:

Yes

Insurance Company:

Policy #

Subscriber:

Insurance Co. Phone #:

Camper Medications– Please list any medications the camper is currently taking and dosage:

Medication

Dosage

Reason for Taking

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.

Signature of

Parent/Guardian:(Required)

Date

Name (please print):(Required)

After School / Sumer Camp

Site Information
Please indicate the desired enrollment site:

Building Blocks Childcare (K -5th) 1310 N. Michigan 48602

Guided Grace FYS (6th –8th) 1232 N. Michigan 48602

New Birth Missionary Baptist (K- 8th) 3121 Sheridan Rd. 48601

After School/Summer Camp Enrollment Form

Child Information

Parent Information

Parent Information Continued

Emergency Contacts

Authorized Pick Up List

After School / Sumer Camp

School Age Immunization Waiver

After School / Sumer Camp

Permission to Photograph

Summer Camp Medical Form

Additional contact in the event that the parents/guardians can’t be reached

Parent/ Guardian Authorization for Health Care

Signature of

After School / Sumer Camp

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NAVIGATION

CONTACT INFO:

ADDRESS:

OFFICE HOURS: