2024 Summer Camp at Sanborn!

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2024 Summer Camp at Sanborn!

Registrations will be processed on a first-come, first-serve basis. Spots will fill up fast, and your spot is not confirmed until payment is received.

Financial assistance is available to families who qualify.

For registration questions, email kgrella@sau17.net

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Child's Last Name *

Child's First Name *

INCOMING Grade Level (where will they be in September) *

Student's Primary FULL Address *

Mailing Address (if different from above)

Parent/Guardian Name *

Parent/Guardian phone number *

Parent/Guardian email address? *

Student's Date of Birth (mm/dd/yyyy) *

Emergency Contact: Full Name *

Emergency Contact: Phone Number
*

Emergency Contact's Relation to Child: *

Emergency / Health Information:

Please complete this form. This information will be shared with the nurse who will be on duty during the summer enrichment camp.

Daily Medications: (include name and dosage amounts)

Allergies: Please use this space to list any known allergies (food, drug, environmental) the student has

Health Concerns? Please use this space to describe any the student has

Pediatrician Name *

Pediatrician Address *

Pediatrician Phone Number *

Emergency Hospital Preference *

Medical Release: By checking the box below, you recognize that the information on this form may be shared with school staff and emergency personnel as appropriate. *

I understand

Wymagane

Accidents and Emergencies: By checking the box below, you recognize the following: In case of accident or serious illness, I request the school to contact me. If the school is unable to reach me, I hereby authorize the school to call the physician and emergency contact indicated and follow his or her instructions. If it is impossible to contact the physician, the school may make whatever arrangements seem necessary as per the nurses discretion. *

I understand

Wymagane

Medication: The health office will stock the following medications and will administer those checked off by a parent or guardian. These will be administered according to the package directions at the discretion of a staff member. Please place an “X” in front of those medications the school nurse may administer to your child. *

All medications listed below

Tylenol or generic acetaminophen for pain, headache, or fever

Bacitracin ointment or generic to wounds

Caladryl lotion or generic for minor rash or insect bites

Hydrocortisone cream ½% for minor rash or insect bites

Topical oral anesthetic (Orasol, Ambesol, or generic) for minor dental pain

Mylanta, Tums, or generic for minor stomach upset

Throat lozenges / cough drops, for minor sore throat or cough

None of the medications listed above

Wymagane

Assistance with Medication: By checking the box below, you recognize the following: the parent/guardian, authorizes the school administrator to direct members of the school staff to assist my child in taking the above medication and agree that I will not hold liable, any member of the school staff or an individual of official capacity who is directed by me (parent / guardian) and the school administrator to assist my child in taking said medication. *

I understand

Wymagane

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