2019 Terrapin STEM Camp Application
Camper Information
Email address *
Date *
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Time *
Time
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Camper's Last Name *
Your answer
Camper's First Name *
Your answer
Nickname
Your answer
Date of Birth *
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Sex *
Grade Completed *
Camper's Swimming Ability *
How did you hear about Terrapin STEM Camp? *
Parent/Guardian Name *
Your answer
Parent/Guardian Phone Number *
Your answer
Emergency Contact #1 Name *
Your answer
Emergency Contact #1 Phone Number *
Your answer
Emergency Contact #2 Name *
Your answer
Emergency Contact #2 Phone Number *
Your answer
Does your child have diet restrictions? *
If your child has diet restrictions, please provide details. (Note: Please write "none" if applicable.) *
Your answer
Does your child have activity restrictions? *
If your child has activity restrictions, please provide details. (Note: Please write "none" if applicable.) *
Your answer
Are your child's vaccinations current? *
Are there any health concerns of which we need to be aware? (This includes any physical, behavioral or psychiatric concerns.) *
Please describe any health concerns of which we need to be aware. (Note: Please write "none" if applicable.) *
Your answer
Are there any medications, allergies or special needs of which we need to be aware? *
Please describe any medications, allergies or special needs of which we need to be aware. (Note: Please write "none" if applicable.) *
Your answer
I acknowledge that any medication, taken at camp, must be accompanied by a Medication Administration Authorization Form. (Note: This form is specific to youth camps and must be completed by a prescribing physician. The form can be downloaded from our website.) *
I acknowledge that medication, taken at camp, must be stored in its original container, list the camper's name, prescribing doctor, date of expiration and dosage. *
I recognize that too much sunlight may increase my child's risk of getting skin cancer someday. (Note: We highly recommend applying any sunscreen products to your child prior to camp. Campers are not always adept at applying their own sunscreen during the day.) *
I agree that I have evaluated any possible allergic reactions my child may experience by applying the provided sunscreen product to my child at home. *
I agree that I have checked all applicable information regarding the type and use of sunscreen for my child and have trained him/her to use the product accordingly. *
Health Insurance Company *
Your answer
Health Insurance Policy Number *
Your answer
Primary Care Provider *
Your answer
Primary Care Provider Phone Number *
Your answer
I give Terrapin STEM Camp permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment by a certified staff member of Terrapin STEM Camp. I also give permission for my child to be transported by ambulance to an emergency center for treatment. *
I authorize Terrapin STEM Camp to obtain immediate medical care and give consent to the hospitalization and performance of necessary diagnostic tests upon, the use of surgery on, and/or the administration of drugs to his/her child or ward if an emergency occurs when he/she cannot be located immediately. It is also understood that this agreement may only cover those situations which are true emergencies and only when he/she cannot be reached. I understand that the provider will take every effort to contact me and/or my designated emergency contacts. *
I/we will be responsible for payment of my child's medical expenses with the Insurance provider and policy number given on this form. *
Please indicate understanding of responsibility for medical expenses and authorize Terrapin STEM Camp's actions regarding medical emergencies by typing your signature below. *
Your answer
I agree that if my child has a fever or other flu-like symptoms, he/she will refrain from attending camp for twenty-four hours after the last evidence of illness. If he/she becomes ill at camp, he/she will be picked up by a parent or guardian as soon as possible. *
I agree, within twenty-four hours, to notify Terrapin STEM Camp if my child or a member of my household contracts a communicable disease. *
I understand that Terrapin STEM Camp provides limited healthcare for sick or injured students. Due to Maryland health regulations, Terrapin STEM Camp does not administer prescriptive or non-prescriptive drugs, except in the case of metered dose inhalers (hand-held devices) and epinephrine pens. We do provide ice packs and bandages, as needed. *
I understand in the event that a parent or guardian cannot be reached in an emergency, Terrapin STEM Camp administrators will contact local emergency services to obtain treatment for my child. My child will be transported to a local medical facility and will receive care under the direction of licensed medical professionals. I understand I am financially responsible for any care my child may receive. *
I have provided correct medical information for my child and will notify Terrapin STEM Camp of any information changes. *
I understand my child will participate in field sports, camp crafts, indoor/outdoor games, hiking , swimming and other camp activities. All activities include a measure of risk. I understand risks may include a loss or damage to personal property, injury or fatality. *
I understand Terrapin STEM Camp follows safety procedures, but assumes no liability for any loss or damage as a result of student participation. *
I agree that Terrapin STEM Camp, its agents and employees will be held harmless from any liability which may arise out of or in connection with Terrapin STEM Camp programming. *
I acknowledge that camp hours are 9:30am-5:00pm. (Note: Campers may arrive as early as 9:15am and depart as late as 5:15pm.) *
I understand that I must sign my child in at camp arrival and then sign my child out at pick-up. *
I acknowledge that no tuition or extended care refunds will be provided after May 15, 2019. *
I understand that tuition or extended care fees may be transferred to other weeks of the 2019 Terrapin STEM Camp season, depending on the availability of openings. *
I understand that campers who register before May 15, 2019 will receive a complimentary camp t-shirt. (Note: Similar t-shirt styles may be purchased through Terrapin STEM Camp's online store.) *
I understand that Terrapin STEM Camp promotes an atmosphere of collaboration, acts of respect and good sportsmanship. I acknowledge that Terrapin STEM Camp reserves the right to dismiss any camper when the director determines it is in the best interest of the child or the camp. *
I understand that if my child is dismissed from camp, tuition may or may not be refunded. Any refunds will be determined by the director. *
I acknowledge that campers are to be respectful to other campers, to staff and to camp property. *
I understand that parents/guardians will be charged for any damages their camper may cause to equipment or to the facility. *
I acknowledge campers are expected to follow directions and to practice safe conduct. *
I understand campers will remain within sight of camp staff or inform camp staff if, for any reason, they need to move to another location. *
I understand campers must remain on camp premises or at a location designated by camp staff. *
I agree that my camper will wear close-toed shoes or sport sandals and active-wear clothing to camp. (Note: Flip-flop style shoes are prohibited, even on pool days.) *
I agree that my camper will bring modest swimwear and a towel to camp on designated swim days. *
I understand that my camper should share any concerns he/she may have regarding personal health, safety or welfare at camp or concerns they may have that affect the whole group. *
I agree that my camper will be made aware of Terrapin STEM Camp rules and procedures and will be expected to follow them. *
I agree that my camper will take responsibility for his/her actions. *
Please type your signature below to certify that you have read and have agreed to the terms and conditions outlined above. *
Your answer
Please type your signature below to certify that to the best of your knowledge, the supplied information is true, accurate and complete. *
Your answer
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