2017 Summer Youth Application
2017 Summer Youth Application
Which camp are you interested in ?
Required
Student's Name
Your answer
Student Age
Your answer
Student's Current Grade
Your answer
Student's Birthdate
Your answer
Student's Sex
Student's Address
Your answer
Custodial Parent/Guardian
Your answer
Daytime Phone Number
Your answer
Evening Phone Number
Your answer
1st Emergency Contact Name & Phone Number
Your answer
2nd Emergency Contact Name & Phone Number
Your answer
Health History: The following information must be filled in by the parent/guardian. Any changes to this form should be provided to camp personnel upon participants arrival at camp. Please complete the form in detail so that the camp can be aware of your child's needs. Has/des the Participant
Required
Allergies
Required
Which of the following has the participant had?
Required
Date of last Tetanus Toxoid Injection
MM
/
DD
/
YYYY
Does your child have a incontinence concern?
Please list ALL medications (including over-the-Counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire time at camp. Keep it in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration. All medications will be administered by our medical staff. (If none, state so)
Your answer
I authorize the following medication to be administered as needed (click only the ones that can be administered)
Required
Date of last complete physical examination
MM
/
DD
/
YYYY
Explain any restrictions to activity
Your answer
List any food allergies(food, medication, etc)
Your answer
Dietary Restrictions
Are there any other food restrictions/requests that we should be aware of?
Your answer
Name of Physician & Phone Number
Your answer
Does the student have health insurance? If so who is the carrier and the policy number?
Your answer
As parent/guardian, I certify that my child is in excellent health and has no physical, mental or emotional problems which are likely to prevent participation in strenuous physical activity. I give permission for participant to be medically treated for illness occurring or injury sustained during such participation. I certify that I have completed the Health History and Health Questionnaire fully and accurately, and accept full responsibility for any error or omission. I have read the foregoing and fully understand it.
I agree that any photographs and videos taken by I Can Make It! Camp 2.0 or Machining U personnel shall be the property of I Can Make It! Camp 2.0 or Machining U, and may be used by I Can Make It! Camp 2.0 or Machining U, at its discretion, for any publicity, marketing and/or advertising purposes, and I hereby consent to and authorize such use without restrictions. I also give permission for my child to be interviewed about I Can Make It! Camp 2.0 or Machining U by the news media.
Required
T-Shirt Size (Adult)
I Can Make It! Camp 2.0 Only....Requests for cabin assignments must be made in writing by June 23, 2017. We will make every attempt to honor the request but do not make any guarantees.
Your answer
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