Camper Information Form

Registration for day camp is not complete until we receive this form.
Please submit this form as soon as possible after purchasing your child’s ticket for camp.
Your child will not be allowed to begin camp on Day One without this form on file.
Only fill out one form per child

Camper Information Form

CAMPER & PARENT INFORMATION

Camper's first and last name(Required)

Nickname if applicable

Camper's birthday(Required)

Camper's grade(Required)

For Summer camp select grade in Fall. For Spring and Winter break camp select current grade.

Camper's gender(Required)

Which camp is your child attending?(Required)

Parent/guardian 1 name(Required)

First and Last

Parent/guardian 1 phone(Required)

Parent/guardian 2 name(Required)

First and Last

Parent/guardian 2 phone(Required)

Primary contact email(Required)

All camp-related emails will be sent to this address.

Notes

Please provide any other information we need to make camp successful for your child (example: a request to place your child in the same group as a friend, which will be taken into consideration)

Who is authorized to pick up your child?(Required)

They must present a photo ID at pick up.

POLICIES

EMERGENCY & HEALTH INFORMATION

Emergency contact(Required)

Other than parent(s), within a 30-minute drive | First and last name

Emergency contact's relationship to camper(Required)

Emergency contact's phone(Required)

This number will be called if we can not reach a parent/guardian in an emergency or if camper is ill.

Physician's name(Required)

Preferred hospital(Required)

Please note any allergies or physical conditions of which we need to be aware.

Current medications

Please bring a daily dosage of medication. Counselors are not authorized to dispense or to monitor the taking of medications, but will remind campers to take them.

Date of camper's last tetanus shot?(Required)

(This question is required by the American Camp Association as part of Living History Farms' accreditation.)

Are the camper's immunizations up-to-date?

(This question is included as part of our accreditation by the ACA.)

Record of past medical treatment

(This question is included as part of our accreditation by the ACA.)

Are there any activities from which your camper should be exempted from for health reasons?

(This question is included as part of our accreditation by the ACA.)

Camper's insurance carrier and policy number(Required)

(This question is required by the American Camp Association as part of Living History Farms' accreditation.)

AUTHORIZATION FOR TREATMENT

I hereby give my permission to the medical personnel selected by the Day Camp Coordinator to order x-rays, routine tests, treatments, and necessary transportation for the child named above. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Day Camp Coordinator to secure and administer treatment, including hospitalization, for the child named above.

Signature of parent/guardian(Required)

Signature typed here constitutes a legal and binding signature.

Date(Required)

Living History Farms Day Camp program is accredited by the American Camp Association, the only nationwide organization that accredits all types of organized camps.