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Homeschool Science Camp Application Form       [One form per child.  Adults use a different form] *Last name:___________________________________*First name________________ Please use the name on this form that the child wants on a name tag.   Elizabeth may prefer to be called Beth, Robert may prefer Rob, etc. *Circle Sex- M / F *Birth date: ________/________/________ *Age at time of camp: _______ If child's group is combined with another I prefer him/her to be with older / younger (circle one). *Parents' names:(or Guardians) __________________________________________________ *Day Phone____________________________ Evening phone _____________________ Other phones ___________________________________________________________ *Address:_________________________________________________________ *City: _________________________________State & Zip:___________________ *e-mail (GREATLY helps us with back and forth information)_____________________________ *Is this the campers first overnight experience? YES / NO ( c i r c l e  o n e ) *List up to 4 relatives or friends camper would like to room with, if possible 1.___________________________________ 2.____________________________________  3.___________________________________ 4.____________________________________ *Medical & Dental Insurance Co. & Policy #: ____________________________________ _________________________________________________________________________ *List 2 adult friends to contact in case of an emergency if we cannot reach the parents. 1. ___________________________________ Phone: ____________________________ 2. ___________________________________ Phone: ____________________________ *Applicant has or is subject to (if yes, please circle and explain): asthma, diabetes, fainting, heart trouble, convulsions, sleepwalking, bedwetting, etc. Explain: ____________________________________________________________________________ *Allergy or reaction to any medication, foods, etc. Please list and explain: ____________________________________________________________________________ *Describe any condition now requiring regular medication or a restriction of activities for med. reasons: ___________________________________________________________________________ *Describe any mental, emotional, or behavioral problems that would be disruptive to group learning: ___________________________________________________________________ *Special Attention: If the applicant has a special medical problem we require a medical clearance from your family doctor. If it is not forthcoming, we reserve the right not to accept the applicant into the program. Medication to be taken at camp should be checked in with the camp nurse on the first day of camp. *Parents: If you feel there are any circumstances which could produce problems with your child adjusting to camp life, please tell the Camp Director in writing. We will be glad to discuss it with you before your child goes to camp. *PLEASE READ AND SIGN: "I give permission to the staff to administer needed medication to my child. I understand that the Director and all camp staff members will put forth every effort to make this camp a very safe place for my child. In case of an emergency, this will authorize the camp staff, a physician, or hospital to provide medical treatment as deemed necessary. I will not hold the Director or any staff members liable in case of an emergency or accident. I promise to pay all medical expenses if my child gets sick or injured. I affirm that the tetanus inoculation is current" Signed: _________________________________________________date ______________ Print campers name again (in case page 1 and 2 become separated) _______________________________________ Notes to camp staff if desired:     Medicine: When sending prescription medicine for children the pills need to be in the original container with a legible prescription label that is not out of date. A camp nurse cannot give out medicine that is labeled for someone else and cannot give a dose that is different than what the doctor ordered.  When medicine is purchased in large amounts and repackaged by the family, send along a copy of the original container and a copy of the prescription     When sending over the counter medicines, parents need to leave them in the bottle or box they were purchased in and clearly write how many their child usually takes. Parents need to understand that a camp nurse cannot give an unusually large dose of prescription or over the counter medicine unless there is a copy of a prescription from the childs doctor giving the larger amount to be given. This includes vitamins and herbals. When medicine is purchased in large amounts and repackaged by the family, send along a copy of the original container and a copy of the prescription        For children with Asthma: Please send their inhalers even if they have not needed them in a long time. An asthma attack may occur at camp due to allergies, stress, or different food.