Board of Directors
Summer 2021 HEALTH HISTORY, AUTHORIZATIONS, AND TERMS OF AGREEMENT FORM
Parent or guardian, please complete. Your child's summer instructor will have access to the information given below. Parents must submit a physician-signed physical exam (no older than one year) by June 15, 2021. Copy of 2020-21 school physical is OK. Note on doctor's letterhead is also acceptable. NO CHILD WILL BE ALLOWED TO ATTEND CAMP WITHOUT A COPY ON FILE HERE OF PHYSICAL EXAM (PERFORMED WITHIN ONE YEAR OF THE DATE OF CAMP ATTENDANCE).
Grade Completed as of June 2021 (Note: Children are grouped by last grade comleted)
Address Line 1
Address Line 2
Home Telephone #
The following people are authorized to pick up my child at the end of the camp day. (Please include spouse.)
Please include: Name, Relationship, and Telephone
Authorized Person #1
Authorized Person #2
Authorized Person #3
Authorized Person #4
Please send your child to camp with a signed letter if a person other than those listed on this form will be picking up your child. Note: Camper will stay with staff until an authorized person picks up your child.
ALLERGIES (food, drugs, plants, insects, etc.)
List any allergies:
Does your child carry an Epi-Pen or other medicine for emergency use in the case of an allergic reaction? If yes, please list them and ACTION PLAN for their use.
TERMS OF AGREEMENT
• CHANGES: If you need to change a week of camper’s enrollment, a $25 administrative fee will be charged per child for each week registered if space is available. (This fee may be waived for extraordinary reasons.) Fees NON-REFUNDABLE after June 15th, 2021 • Parents are responsible for providing transportation and *lunch. On Wednesdays and Fridays, your child can opt for pizza (Wednesdays) for a fee of $6 and for a burger or hotdog on grill day (Friday) for a fee of $6. If you did not sign your child up for these lunch options when you registered, you may do so on an as-desired basis, provided you pay the $6 charge the day prior so that appropriate amounts of food will be be available • Permission is granted for SMLI to take and use photographs for its publicity and marketing purposes. (No campers’ names will be used on such photos.) • In the event of an emergency, parent authorizes SMLI to administer medication (such as injection of Epi-Pen and oral administration of Benadryl in the event of a severe allergic reaction), or to obtain emergency medical care and/or provide basic first aid measures should any of these be necessary during camp hours • SMLI is not responsible for any damaged, stolen, or misplaced property • SMLI reserves the right (and, indeed, considers it a responsibility) to dismiss any camper for improper behavior. Improper behavior includes, but is not limited to persistent rudeness to or bullying of others, repeated failure to obey the reasonable requests made by teachers or staff, and the deliberate misuse or destruction of supplies/materials used in activities. Dismissal has never been necessary in any camp year but parents understand that no refund(s) will be given should such a step be deemed necessary • Parent guarantees camper’s physical fitness to participate in camp activities and agrees to hold harmless SMLI, its employees, and agents from any and all liability arising from a camper’s participation in the activities carried out at camp. Either a letter of medical clearance from camper’s physician or a copy of camper’s school physical examination (no older than one year prior to the start of camp) must be on file with SMLI no later than two weeks prior to the start of camp. As stated elsewhere, camper will not be admitted to camp unless medical form is on file and no refund(s)/credit(s) will be issued for day(s) missed for this reason • No refund(s)/credit(s) will be issued for day(s) missed due to illness • By submitting this form, I agree to the Terms of Agreement, above.
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