Camper Information

Child’s Name: ______Age: ______Birth Date: _____/_____/_____

Address: ______City: ______State: _____ Zip Code: ______

Name of Mother/Guardian: ______Day Time Phone ______

Name of Father/Guardian: ______Day Time Phone ______

Email Address: ______

Name of Person(s) Authorized to Pick Up Your Child:

(In an emergency or illness, we will call you first and then those you list here if we cannot reach you.)

NamePhone NumberRelationship

We will not release your child to anyone that is not on this form.

I am signing my child up for Part Time(3 days a week) or Full Time(5 days a week) care.

T-Shirt Sizeplease circle: (Child) or (Adult) and Size S M L XL

Health History

______Bleeding/Clotting Disorder ______Heart Defect/Disease ______Convulsions/Epilepsy

______Hypertension ______Asthma______Poison Ivy, etc.

______Heat/Sun-Related Problems ______Mononucleosis ______Hay Fever

______Frequent Ear Infections ______Diabetes______Insect Stings

______ADD/ADHD______Autism______Insect Repellent

______Any Special Health/Behavioral Considerations: ______

______Any Physical Limitaitons:______

Does this child have any known drug allergies of any kind?

No Yes- please list the medicine(s) to which the child is allergic.______

Are your child’s immunizations up to date? No Yes

Is your child’s tetanus up to date? No Yes

Is your child covered by medical insurance? No Yes

(please provide a copy of immunization record and insurance card)

Child’s Physician: ______Phone: ______

Does your Child have any Food Allergies? No Yes- Please list: ______

Medical Release

(PLEASE CHECK YOUR PREFERENCE and PROVIDE A COPY OF IMMUNIZATIONS & INSURANCE CARD)

This health history is correct to the best of my knowledge. The person herein described has permission to engage in all prescribedcamp activities except as noted. I have reviewed and consent to the Camper Release Policy and the camper Code of Conduct.

I give permission to The Salvation Army Muskegon, MI Day Camp, which is licensed by the State of Michigan, to secureemergency medical and surgical treatment (including, but not limited to, x-rays, routine tests, injections, and anesthesia) and hospitalization for this child if there is insufficient time to contact me. I further authorize routine, non-surgical medical care (including dispensing of non-prescription drugs for illness, injury treatment, insect bites, & repellant, sunscreen, etc.) at the discretion of the camp health officer or other first aid certified staff.

I do not give permission to The Salvation Army, to secure emergency medical and surgical treatment forthis child due to my religious objection. If there is a religious objection, the authorized person must submit a written statement to the effect that the camper is in good health and that the person signing assumes the health responsibility for the camper.

Parent Signature: ______Date: ______

Consent to Publication

(PLEASE CHECK YOUR PREFERENCE)

GRANTED- I understand that photographic images of my child may be used for programming, slide shows or publication (The Salvation Army Facebook Page, Website).

DENIED (PHOTO ATTACHED- I am attaching a current photo to the application as a means of identifying my child in photos.)

Day Camp Agreement

I give my child, ______permission to attend The Salvation Army of Muskegon’s Summer Day Camp and to be transported by the Salvation Army for all field trips.

I understand:

  • My child is required to attend all field trips each week.My child will be included in all swimming sessions unless I notify the camp otherwise, and will still go to the lake since the center will be closed during swimming sessions. I also agree to provide a modest swimsuit and towel for my child.
  • I will not hold The Salvation Army or its leaders responsible if my child is injured during a field trip or swimming session and that I will be notified immediately if any such emergency were to occur.
  • It is my responsibility to notify camp staff if my child is taking medications, and that all medications should be given to and dispensed by the health officer.
  • Only adults listed on the application have permission to pick up my child.
  • The Salvation Army and its leaders will not be held responsible for any items brought from home that are lost, damaged, or stolen while at day camp. This includes but is not limited to electronics, clothing, or phones.
  • All fees are due on Monday for that week of care; I will be billed for the care that I request. The Salvation Army retains the right to terminate my child from the program for a failure to pay all fees.
  • The Salvation Army is a Christian non-profit organization and that the summer camp is religious in nature.The Salvation Army operates a no-bully camp. If my child refuses to cooperate, becomes violent and/or threatens other campers and/or staff, making an unsafe environment, The Salvation Army may terminate my child from the program (as a last resort) and I am still responsible for that week’s fees.

Parent Signature: ______Date: ______

2017 Registration Schedule for:

To help us best staff our day camp, please select the weeks of care that you anticipate a need for. This schedule allows us the information needed to schedule our staff accordingly.

Full Time Part Time No Care Needed

1 / June 19-23
2 / June 25- 30
3 / July 3-7 (closed July 4)
4 / July 10-14
5 / July 17-21
6 / July 24-28
7 / July 31-August 4
8 / August 7-11
9 / August 14-18
10 / August 21-25

You will be billed according to the boxes marked above unless you give a change of schedule one week in advance of the needed change.

Thank you,

Major Stephanie