Arkansas Vault Club ~ Summer Camps 2020
Name and date of birth?
Check any that apply. These screening questions will be asked again at check in.
Have had fever 100.4 or greater in the last 2 days.
Have a cough, difficulty breathing, sore throat or loss of taste or smell.
Have had contact with a person known to be infected with COVID 19 in the previous 14 days.
Have returned from overseas travel or from states/areas considered hot spots for COVID-19.
Have recently had pneumonia.
None of the above.
List emergency contact/number and insurance information.
Do any of these apply to the camper?
wear glasses, contacts or protective eyewear
had a recent injury, illness or disease
have problems with sleepwalking
had a seizure
takes prescribed medication for a medical condition
none of the above
If you checked any of the above or 'other', please explain.
Does the camper have specific dietary needs (vegetarian, lactose intolerant, etc)? If yes, explain.
Any further information we need to know?
Parent/Guardian Authorization: By signing my name below I attest the personal and medical information is correct and complete as far as I know. The person described has my permission to engage in all camp activities. I give permission to the camp to provide routine health care, administer prescribed medications, and seek emergency medical treatment including ordering x-rays , routine tests, and treatment. I agree to the release of any records necessary for insurance purposes. I give permission to the camp to arrange necessary related transportation for me/my child.In the event that I cannot be reached in an emergency, I give permission to the physician selected by the camp to secure and administer treatment, including hospitalization for the person named above.
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This form was created inside of Caddo Hills School District.