Summer Day Camp Authorization

Summer Day Camp Authorization Form
Camper's Name*
First Last
Parent's Name*
First Last
Parent's Email Address*
Enter Email Confirm Email
COVID-19 Policies
COVID-19 Vaccination Card OR Negative PCR result 72 hours or less before 1st day of camp
Accepted file types: jpg, jpeg, png, gif.
Please upload image of Vaccination Card or Negative PCR test results 72 hours or less before 1st day of camp.
COVID-19 Attestation Form must be filled out the Sunday before camp.
Spray Sunscreen Authorization
Spray Sunscreen
- By checking this box I authorize Pass Academy 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 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
Additional Emergency Contact
If there is a medical emergency and you or another parent/guardian cannot be reached, we will attempt to contacy your Emergency Contacts.
Name
First Last
Relationship
Phone
Health Contact
Doctors Name
Doctors Phone
May we contact your child's health care provider?*
- Yes
- No
Diseases
Tuberculosis Test Date or N/A
Tuberculosis Result or N/A
COVID-19 Last Occurrence or Never
Chicken Pox Last Occurrence or Never
German Measles Last Occurrence or Never
Hepatitis A Last Occurrence or Never
Hepatitis B Last Occurrence or Never
Hepatitis C Last Occurrence or Never
Measles Last Occurrence or Never
Mumps Last Occurrence or Never
H1N1 Last Occurrence or Never
Immunizations
Date of Tetanus, Pertussis Booster
Required Immunizations:
- By checking this box I attest that all of my child’s immunizations required for school are up to date.
No Immunizations:
- My child has not received any immunizations.
Physical Health History
Date of Authorization*
Month
Day
Year
By dating above, I affirm this health history form is correct and complete to the best of my knowledge and that I have read, understood, and agree to the Terms and Conditions specified in this form.

Summer Day Camp Authorization

Summer Day Camp Authorization Form

COVID-19 Policies

Spray Sunscreen Authorization

Medical Plans

Additional Emergency Contact

Health Contact

Diseases

Immunizations

Physical Health History