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Get IL Camper Information Form - Skokie Park District

CAMPER INFORMATION FORM Skokie Park District CAMP NAME S SESSION I 6/10-7/5 2013 SESSION II 7/8-8/2 2013 The following information is confidential and will be kept on file in the camp office. Camper s Name Address Birth Date Age Grade Entering Male Female Grouping Request optional one friend only may not apply to all camps Mother/Legal Guardian E-mail Address to receive weekly camp newsletter Home Phone Pager/Cell Phone Work Phone Work Address/City Parents are living together separated Child s Physician divorced other Phone Does your child have any special needs medical conditions or restrictions to the type of activities he/she can participate in yes no Explain Are your child s immunizations up to date When was your child s last tetanus shot Fears/phobias Is medication required during camp hours If yes please complete Medical Consent Form* Please rate your child s swimming ability good average Child s weight for boating life vests Emily Oaks camps only OVER poor non-swimmer TRANSPORTATION AUTHORIZATION How will your child be transported to and from camp Please mark the means of transportation and provide your signature for authorization* CAMP BUS SERVICE separate registration required SELF CHECK-OUT Walk / Bike / Public Transportation My child has permission to sign/check themselves in and out of camp each day. Prior to sign-in and after checkout they are responsible for their own transportation and will not be under staff supervision* CAR Family Member / Carpool Please list those authorized to transport your child to and from camp other than yourself. In the event that someone who does not usually transport your child should arrive for pick-up they will be requested to produce a photo ID before a child will be released* Name Relation Signature of Parent/Legal Guardian Date AUTHORIZATION TO PARTICIPATE IN OUTDOOR ACTIVITIES be scheduled on a daily basis weather permitting. See camp calendar for field trip dates and times. EMERGENCY NUMBERS reach you. Please list individuals other than the legal guardians. Camper s Name Address Birth Date Age Grade Entering Male Female Grouping Request optional one friend only may not apply to all camps Mother/Legal Guardian E-mail Address to receive weekly camp newsletter Home Phone Pager/Cell Phone Work Phone Work Address/City Parents are living together separated Child s Physician divorced other Phone Does your child have any special needs medical conditions or restrictions to the type of activities he/she can participate in yes no Explain Are your child s immunizations up to date When was your child s last tetanus shot Fears/phobias Is medication required during camp hours If yes please complete Medical Consent Form* Please rate your child s swimming ability good average Child s weight for boating life vests Emily Oaks camps only OVER poor non-swimmer TRANSPORTATION AUTHORIZATION How will your child be transported to and from camp Please mark the means of transportation and provide your signature for authorization* CAMP BUS SERVICE separate registration required SELF CHECK-OUT Walk / Bike / Public Transportation My child has permission to sign/check themselves in and out of camp each day. Prior to sign-in and after checkout they are responsible for their own transportation and will not be under staff supervision* CAR Family Member / Carpool Please list those authorized to transport your child to and from camp other than yourself. .

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