Summer Camp Registration 2025
Additional information required for summer camp program participants.
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Email *
Child's First Name *
Child's Last Name *
How did you hear about us? *
Summer at Independence uses photos and videos to share, communicate, collaborate, and promote our program on social media (Facebook & Instagram), our website, and in weekly summer camp newsletters. If you do not wish the school to use photographs of your child please indicate "No" and explain. Otherwise, please indicate "Yes." *
Physician: Name/Phone *
Dentist: Name/Phone *
Medical Insurance Company *
Medical Insurance Numbers *
Indicate child's medical problems and any medicines taken routinely. (Indicate N/A if none) *
Indicate any child's allergies to: Food, Medicine or other (be specific).  If child has an allergy is an EpiPen needed?  (Indicate N/A if none) *
Does the camper require any special services? If yes, please describe.   (Indicate N/A if no) *
Has your child ever been stung by a bee?  If yes, please describe reaction.   (Indicate N/A if no) *
Permission for nurse to dispense over the counter medication: *
Yes
No
Cough drops
Acetaminophen (Tylenol)
Ibuprofen (Motrin)
Benadryl
Neosporin
Hydrocortisone/Caladryl
Sunscreen

THE INDEPENDENCE SUMMER CAMP has adopted the following procedures in caring for your child when he/she becomes sick or injured (non-emergency) at CAMP.  

1. The nurse/camp director will call the home and/or cell phone.  

2. An email may also be sent.  If there is no immediate answer, 

3. The nurse/camp director will call the mother's and/or father/s place of employment.  If there is no answer,  

4. The nurse/camp director will call the other emergency number(s) listed.  

5. The nurse/camp director will continue to call the parents and other contacts listed until one is reached.  

The Independence School reserves the right to call an ambulance at any time if deemed necessary to transport the child to a local medical facility.  Based upon the medical judgment of the attending physician, the child may be admitted to a local medical facility.  

I agree to assume all expenses for moving and treating this child.  I also consent to any treatment, surgery, etc., which may be carried out based on the medical judgment of the attending physician.  It is also understood that this digital signature may be photocopied.

Parent/Guardian Signature:

 *
Date of Submission/Authorization *
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