Summer Day Camp Authorization

Summer Day Camp Authorization Form

Camper Information

Camper's Name*

First Last

Age*

Please enter a number from 5 to 15.

Date of Birth*

Grade*

School*

Household Contact Information

Contact #1 Home Phone

Contact #1 Mobile Phone

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent 1

First Last

Parent 1 Email Address

Parent 1 Work Phone

Parent 1 Mobile Phone

Parent 1 Other Phone

Parent 2

First Last

Parent 2 Email Address

Parent 2 Work Phone

Parent 2 Mobile Phone

Parent 2 Other Phone

Emergency Contacts

In the event that you or another parent/guardian cannot be reached, please provide two alternate contacts, other than the parents listed above.

Emergency Contact 1

First Last

EC-1 Relationship

EC-1 Phone

Emergency Contact 2

First Last

EC-2 Relationship

EC-2 Phone

Authorized Grown Ups

The following people are authorized to pick up my camper.

Authorized Grown Up 1

First Last

AGU-1 Relationship

AGU-1 Phone

Authorized Grown Up 2

First Last

AGU-2 Relationship

AGU-2 Phone

Authorized Grown Up 3

First Last

AGU-3 Relationship

AGU-3 Phone

Authorized Grown Up 4

First Last

AGU-4 Relationship

AGU-4 Phone

Camper Health Information

Physician Name

Or other provider of medical care

Physician Phone

Or other provider of medical care

Are there any health problems including physical, psychiatric, or behavioral problem of which we need to be aware?

Health Problems?*

No
Yes

If Yes, Explain (H)

Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child's camp experience is positive?

Medications/Restriction?*

No
Yes

If Yes, Explain (M)

For campers who currently reside within the United States, a United States territory, or the District of Columbia: Does the camper have any immunization exemptions because of a parental or guardian objection or medical contraindication?

Immunization Exemption?*

No
Yes

If Yes, List

For campers who reside outside the United States, a United States territory, or the District of Columbia: Email record of vaccination or immunity on Department from MDH-896 to director@passacademybullis.com.

Consents

Informed Consent*

By checking this box and dating below, I agree to the terms and conditions expressed herein. While Bullis and Pass Academy will make every reasonable effort to keep all students safe from injury, illness, and harm, accidents do happen. I understand that there may be risks and hazards associated with the camp, and have had an opportunity to ask questions and to receive answers concerning those risks. I acknowledge that it is my responsibility to evaluate the risks associated with my camper's participation in this camp to determine whether my camper should participate and to discuss these risks with my camper. By checking this box, I agree on behalf of myself and my minor child to assume all risks associated with this camp and further to release and hold harmless Bullis and Pass Academy, its officers, trustees, agents, employees, volunteers, and trip leaders/chaperones, and agree to indemnify each of them from any and all claims, costs, suits, actions, judgments, and expenses, upon any damage, loss or injury to my camper or damage or loss to my camper's property (including all property of others in my camper's possession or control) arising out of my camper's participation. These agreements of release and indemnity include claims of negligence, but not of gross negligence or intentional wrongful conduct.

Informed Consent Date*

Medical Authorization*

By checking this box and dating below, I request and authorize Bullis Summer Programs and Pass Academy staff to administer basic first aid and or take my camper to a physician or hospital for emergency treatment in the event it appears necessary and a parent or guardian cannot be contacted in a timely manner as Bullis or Pass Academy deems appropriate under the circumstances. I give to any physician, dentist, hospital, or other health care provider consent to perform any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment under the supervision of any licensed physician or dentist. I agree that I will be financially responsible for the costs of such treatment and transportation.

Medical Authorization Date*

Photo Release*

Yes
No

I am aware and give consent for photographs and video segments containing the image of my camper to be used for future publications, in print and electronic formats.

Religious Objection

By checking this box, I am the parent/guardian of the camper identified above. Because of my bona fide religious beliefs and practices, I object to any immunization being given to my camper.

This consent only needs to be checked and dated if the parents/guardians of the camper identified above object to immunization for religious reasons.

Religious Objection Date

Spray Sunscreen Authorization

Spray Sunscreen

By checking this box I authorize Pass Academy and Bullis Summer Programs staff to apply spray sunscreen, as needed, to my camper. I understand it is my responsibility to apply sunscreen to my camper before camp begins each day and to provide Pass Academy staff with a container of spray sunscreen clearly labeled with my camper's name.

Pass Academy is only allowed to apply spray sunscreen which is provided by the camper. Please pack spray sunscreen in your camper's backpack or bag, and clearly label it with your camper's name.

Medical Plans

Please print & fill out any or all the following 4 forms if needed. Either email filled out forms to director@passacademybullis.com or bring and give to the tennis director at drop off.

Allergy Action Plan

Asthma Action Plan

Medical Administration Action Plan

Seizure Action Plan