Youth Summer Camp Critical Information Form - H2o Dreams Paddling School

Participant Information

Please fill out the following form as detailed as possible. Information given will be treated with the strictest confidentiality. Any vague or incorrect information could result in the injury or death of yourself or to other participants.

Name *

Date of Birth *

Phone *

Email *

Medical Insurance Company

Insurance Policy Number

Emergency Contact Information

In case of emergency, please contact

Name *

Relationship *

Phone *

Email *

H2o Dreams Administration of Medication Authorization

We encourage all parents/guardians to administer all physician prescribed medication(s) to their child before or after a H2o Dreams sponsored program. However, we understand that some cases may arise when the day camp’s part-time/full-time supervisor may be requested to administer medication. By completing the information below, the H2o Dreams part-time/full-time staff is authorized to administer physician prescribed medication(s) that are stored in a current prescription bottle(s).

Parent’s Name

Child’s Name

Name of care providers authorized to administer prescribed medication *

H2o Dreams part-time/full-time staff is authorized to administer physician prescribed medication (s) that are stored in a current prescription bottle(s)

yes

Medication(s):

List medication(s) to be administered

Dosage:

Time(s):

Special Instructions (ie: on full/empty stomach, etc.)

Possible Side Effects:

Parent Signature

Reset Signature

H2o Dreams Camper Release Authorization Form

H2o Dreams campers may only leave with an authorized person carrying a valid ID, age 16 or older that are designated in the H2o Dreams Camper Release Authorization Form.

Camper’s Name

Main pick-up person:

Name

Relationship:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Additional persons who may pick up child/children on a less frequent basis:

Name

Relationship:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Name

Relationship:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

The following person(s) NOT authorized to pick up my child/children:

Note: Any person unfamiliar to H2o Dreams staff will be required to show proof of identification. Under NO circumstances will the child be released to anyone other than those listed above without WRITTEN permission from the parent.

By submitting this form, I certify and acknowledge that I have read this document thoroughly and that all the information I have provided is correct and accurate. *

I agree

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Youth Summer Camp Form

Participant Information

Emergency Contact Information

Vital Information

H2o Dreams Administration of Medication Authorization

H2o Dreams Camper Release Authorization Form

Main pick-up person:

Additional persons who may pick up child/children on a less frequent basis:

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