Staff/Volunteers may have access to information about my child, which may be relevant to his/her participation in Camp programs. I understand that only necessary information will be disclosed and that all reasonable steps are taken to protect the privacy and confidentiality of my child's information.
Age
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Birth Date
Phone Number
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Address
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Apt/Unit #
City
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State
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Zip
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Grade Level (2022-2023)
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Name of School
Primary Diagnosis
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Number in Household
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Household income
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Parent/Guardian Name
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Phone Number
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Alternative Phone Number
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Address
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Apt/Unit #
City
*
State
*
Zip
*
Email Address
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Parent/Guardian Name - Required if Applicable
Phone Number
Alternative Phone Number
Physical Address
Apt/Unit #
City
State
Zip
Email
Mailing Address (if different)
Apt/Unit #
City
State
Zip
Emergency Contact #1 Name
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Emergency Contact #1 Phone Number
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Emergency Contact #1 Relationship to Camper
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Emergency Contact #1 Authorized to Pick up/transport
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Emergency Contact #2 Name
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Emergency Contact #2 Phone Number
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Emergency Contact #2 Relationship to Camper
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Emergency Contact #2 Authorized to Pick up/transport
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Name of Insurance Carrier
*
Policy #
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Policy Holder
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Group #
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Insurance Phone #:
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Child's Name
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AUTHORIZATION FOR MEDICAL SERVICES
Child's Name
*
I, the parent/guardian of ________________ have read the above statement regarding the authorization of emergency medical services in the event I cannot be reached. I designate CTHF Executive Director and/or Service Coordinator to authorize medical attention, hospitalization, and surgery as may be required in an emergency because of illness or injuries sustained by my child while participating in Camp Adventure. I hereby assume financial responsibility for hospitalization, medical attention, and surgery provided.
Medical Concerns and List Allergies
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Please List all Medications (prescriptions/OTC) Including Dosage
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Date
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List of Services Received at Carrie TIngley Hospital and Clinics
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Date of Last Clinic Visit
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Medical Condition Details
Does your child use any special equipment?
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ACTIVITIES OF DAILY LIVING (ADL)
If yes, explain the assistance needed:
Please explain
Communication Skills (Other)
Language(s) spoken/understood:
BEHAVIOR
If yes, please explain:
Are there certain behaviors that your child is working on at school/home that should be encouraged while at camp? Please explain.
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What motivators (e.g., toys, activities, foods) will be strong reinforcers for your child?
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Please list any triggers that might agitate your child. (e.g., loud noises, odd textures, etc.)
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What is the best way to assist your child if he/she gets overwhelmed or upset?
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If Yes, please explain:
If No, please explain:
Does your child have trouble with transitions? If so, how can I make transitions easier for him or her?
ADDITIONAL INFORMATION
Any specific activities to be encouraged?
Any specific activities to be discouraged?
Does your child use any special equipment?
With what might your child require assistance?
CAMP ADVENTURE
give my permission and approval the use of my child’s image, name, biographical information and/or audio recording to be used by Carrie Tingley Hospital Foundation as part of its fundraising efforts, advertising, publicity, promotion or any other use. I understand and agree that my image, information and/or audio recording may appear in any media now known or hereafter invented including but not limited to print materials, video, online presentations, or other media. I hereby waive any right to inspect and approve the uses to which it may be applied. Nothing herein will constitute any obligation on the Carrie Tingley Hospital Foundation to use any of the above rights.
Child's Name
*
Parent/Guardian Name (Please Print)
*
Date
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If you are human, leave this field blank.
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