CREATE 2021 Summer Camp Health Form
Please complete the following form regarding your child's health history accurately and to the best of your knowledge. You will need to complete a separate form for each registered child. If you would like to discuss any health concerns, please contact us at 301-588-2787 or
Last Name of Child Attending Camp
First Name of Child Attending Camp
Date of Birth
Prefer not to say
Please check ALL sessions for which your child is registered:
Session 1 (June 14-18 [includes full week AND individual day registrations])
Session 2 (June 21-25)
Session 3 (June 28 - July 2)
Session 4 (July 5-9)
Session 5 (July 12-16)
Session 6 (July 19-23)
Session 7 (July 26-30)
Session 8 (August 2-6)
Session 9 (August 9-13)
Session 10 (August 16-20)
Session 11 (August 23-28)
Name of Parent/Guardian Completing and Submitting Form
Please check boxes for any known allergies
No Known Allergies
Environmental Allergies (pollen, bee stings, etc)
If your child has an allergy listed above, please describe the allergy, typical reactions seen, and medications taken.
Will your child require any medications while at camp?
All medications brought to camp must be clearly labeled with child's name and any instructions for use. Unless otherwise indicated, medications will remain in the office during the day.
If you answered "YES" to the previous question, please provide the name of medication(s), dosage, and instructions.
Please share any learning differences, notes about your child’s behavior, strategies that work well inschool and at home, etc. This will help us to ensure that we can help your child have the best possible experience at CREATE!
I understand that:
Please check each box below to indicate that you have read and understand the following.
CREATE reserves the right to check the temperature of my child at check-in, and during the day if needed.
If my child has a temperature reading over 100.4°F they will not be permitted to attend camp for the week.
If my child displays any symptoms of illness during the camp day, I will be available (or a named parent/guardian) to pick my child up from camp within 1 hour of being called by a CREATE staff member.
Never submit passwords through Google Forms.
This form was created inside of CREATE Arts Center Inc..