Camper Full Name
*
Name Camper Goes By
Age
*
Gender
Prefer Not to Answer
Male
Female
Prefer Not to Answer
Rising Grade Level
*
T-Shirt Size
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Camp Session
June 9-13 (for rising 1st and 2nd graders)
June 16-20 (for rising 3rd and 4th graders)
June 23-27 (for rising 5th and 6th graders)
Additional Information
(Optional) If you want to clarify any of your answers above or tell us anything else you'd like us to know, please do so here.
Home Phone
*
(###)
###
####
Cell Phone
(###)
###
####
Parent/Guardian
*
Parent/Guardian
Parent/Guardian Home Phone
*
(###)
###
####
Parent/Guardian Cell Phone
*
(###)
###
####
Parent/Guardian Work Phone
*
(###)
###
####
Parent/Guardian Email
*
Relationship to Camper
*
Parent/Guardian Occupation
*
Mailing Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Camper Address
If different from Mailing Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Name
*
Relationship to Camper
*
Emergency Contact Mailing Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Home Phone
*
(###)
###
####
Emergency Contact Cell Phone
*
(###)
###
####
Emergency Contact Work Phone
*
(###)
###
####
Emergency Contact Email
*
Name of Camper's Physician
*
Physician's Phone Number
*
(###)
###
####
Is the camper covered by medical insurance?
*
Yes
No
Is the camper up-to-date with all immunizations required for school?
*
Yes
No
Date of last tetanus shot?
*
MM
DD
YYYY
If an allergic reaction occurs, please list the steps necessary to relieve the reaction (EPI PEN, Benadryl, etc.)
*
Is the camper bringing medications to camp?
*
Yes
No
If yes, please explain
If you have indicated that your camper is bringing medications (either prescribed or OTC), you will be asked later in the registration process to provide the medication information as well as create a schedule of when the medication(s) need to be dispensed. This needs to be completed 1 WEEK PRIOR to the start of the camp session.
*
Yes, I understand
Does your camper currently receive services at school for any physical, emotional, or behavioral needs?
*
Yes
No
If yes, please explain:
Does your camper wear protective eyewear like glasses, contacts, etc.?
*
Yes
No
If yes, please explain
Are there any emotional or behavioral conditions which might affect camp experience (ADD,ADHD, etc.)?
*
Yes
No
If yes, please explain
Has there been any previous hospitalization?
*
Yes
No
If yes, please explain
Does your camper have current or previous counseling?
*
Yes
No
If yes, please explain
Are there any disabilities, chronic or recurring conditions such as asthma, fainting, or nosebleeds?
*
Yes
No
If yes, please explain
Are there any dietary restrictions?
*
Yes
No
If yes, please explain
Does your child have diabetes or related illness?
*
Yes
No
If yes, please explain
Does your child experience seizures?
*
Yes
No
If yes, please explain
Does your child need insulin?
*
Yes
No
If yes, please explain
Are there any other important health considerations?
*
Yes
No
If yes, please explain
This authorization allows us to assist with the application of sunscreen if needed. Your child will be in possession of their own bottles. Sunscreen will be provided by the parent/guardian and labeled with the child's first and last names. In the case of all non-prescription sunscreen, any staff member may apply the product. Dosage and times to be administered: As needed when weather/season is appropriate not to exceed label recommendations and usage instructions.
*
Please list any known adverse reactions to sunscreen.
This authorization allows us to assist with the application of insect repellent if needed. Your child will be in possession of their own bottles. Insect repellent will be provided by the parent/guardian and labeled with child's first and last names. In the case of all non-prescription insect repellent, any staff member may apply the product. Dosage and times to be administered: as needed when weather/season is appropriate not to exceed label recommendations and usage instructions.
*
Please list any known adverse reactions to insect repellent..
By checking this box, I am verifying that the information provided on this form is up to date for my camper.
Date
MM
DD
YYYY
Emergency Authorization
I, as parent or guardian of a camper, give permission to the medical or dental personnel selected by the Director to order x-rays, routine tests and treatment for the camper. In the event I cannot be scared in an emergency, I hereby give permission to the physician or dentist selected by the Director to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for the camper.In the event of a serious allergic reaction or condition requiring immediate attention on site, I authorize the Director or personnel selected by the Director to give the appropriate medication which can include but not be limited to: dpi pen, or Benadryl. I further acknowledge I will be responsible for the payment of all charges related to the medical or dental services for the camper beyond the limited of the camp's accident and/or liability insurance policy. This for may be photocopied for use outside of camp. If my child becomes ill during camp hours, I agree to report to Lynchburg Grows within 24 hours if any member of the camper's immediate household has developed any communicable disease as defined by the State Board of Health, except for life threatening diseases which must be reported immediately.
We need your consent before accepting your child into the program.
Parent/Guardian Agreement and Authorization
*
I, as parent or guardian of a camper, understand Lynchburg Grows takes responsible precautions to insure the program and activities at Lynchburg Grows are conducted by qualified personnel in a safe and responsible manner. However, I further understand these activities involve certain risks which include, but are not limited to : food preparation, working with hand tools, working with plants and vegetation. I, the undersigned parent/guardian of a camper, individually and on behalf of the camper, recognize these risks and agree to assume these risks by attending or allowing the camper to attend Lynchburg Grows and participate in these programs. I, as parent/guardian, individually and on behalf of the camper, hereby release, discharge, and agree to these programs. I, as parent/guardian, individual and o n behalf of the camper, hereby release, discharge, and agree to save-harmless and indemnify Lynchburg Grows, its Director, Program Directors, Members of the Board, staff and volunteers from all liability for damage, injury, illness, or death to the camper or his/her property relating to or deriving from his/her presence at Lynchburg Grows or participation in or travel to or from Lynchburg Grows activities. I give permission for my child to be transported by Lynchburg Grows to and from approved program activities and/or in case of emergency. I have read and understand the contents of this application, including the Emergency Authorization, the Refund and Cancellation Policy, the Payment Policy, and the Parent Agreement.
We need your agreement and authorization before accepting your child into the program.
Policies Agreement
*
Please read the Payment Policy and Refund Cancellations Policy (on the Camp Grows Web Page) and indicate your agreement here.
Certification
*
The person filling. out this form certifies that the information provided is complete and correct. Please type in your name as an electronic signature.
Name of person filling out this form
*
List Camper's School and School District in the space below:
*
How did you hear about Camp Grows? (Check all that apply)
*
If you selected "Other" in above, please write-in below:
Check the box below to verify the information provided on this form is up to date for the current camp season
*
Name of person filling out this form
*
Date
MM
DD
YYYY
I give consent to Lynchburg Grows to take photographs and / or video of Camp Grows students and grants full rights to use the images resulting from the photography / video filming, and any reproductions or adaptations of the images for publicity or other purposes for the Camp Grows Program. This might include (but is not limited to), the right to use them in printed and online publicity, social media, press releases and funding applications.
*
If you opted out of the media consent form, please list your child's name below.
