Please submit registration
forms and checks to:
Caravel Day Camp
c/o Steven Oliver
21 Breckenridge Drive
Oxford, PA 19363
2014 Science Camp Registration Form
Name of Camper:
___________________________
M____ F____
One child per form, please.
Birth Date:
___/___/___
Grade (recently completed in 2014) ___________
T-shirt Size: YS YM YLYXL AS AM AL AXL School: _____________________
Billing Name:
___________________________
Address:
________________________________________________________
STREET
CITY
STATE
ZIP
Phone Numbers:
Home:
( )
(
Work:
( )
(
Cell phone: ( )
(
_____________________________
Email Address:
Alternate Contact:
)
)
)
-
.
..
.
(
)
PHONE NUMBER
NAME
.
Note: Campers’ pictures may be used in camp promotional material unless parent notifies Camp Director to the contrary.
Day Camp Enrollment Information: Please circle the appropriate weeks.
July 28Aug 1
July 28- Aug 1 is for children going into 3rd , 4th, or 5th grade.
Extended Day Camp Enrollment Information:
Please circle the appropriate week in order to help us gauge attendance.
Before Care: 7:00 – 8:30
July 28Aug 1
Science Camp
After Care: 3:00-5:30
July 28Aug 1
5 days/week
Extended Care
x ____ weeks x $220 / week
x ____ weeks x $15 / week
Total
50% of Total
=
=
=
=
To reserve a spot at Caravel Day Camp, the following forms are due at the time of registration: Registration,
Release of Claims (see reverse), Lunch Request, Camp Health Record, and Medical Release forms. A nonrefundable 50% of the Total is due upon registration in order to reserve a spot for each camper at Caravel Day
Camp. The balance is due on or before 6/16/14. Please note: After 5:30 pm, a $15 per 15 min fee goes into effect.
www.caraveldaycamp.com
Acknowledgment and Release of All Claims
I understand that attending Caravel Day Camp (the “Camp”) and participating in
activities provided by or through the Camp, during Camp hours and during extended day
care hours, carries the possibility of physical illness or injury to my child (or ward). I
hereby assume all risks of and claims associated with any such illness or injury.
Further, I acknowledge that I (as a camper’s parent or guardian) am obligated to provide
personal health insurance coverage for the camper.
As a condition of my child’s (or my ward’s) attendance at the Camp, and participation in
activities provided by or through the Camp, I hereby release Caravel Day Camp, L.L.C.,
its members and managers, its staff (including, without limitation, its director, counselors,
nurse, counselors-in-training, and instructors), and its employees and agents, of and from
any and all claims, demands, actions, and causes of action (collectively, “Claims”) which
I (or my child or ward) have or may ever have or claim to have for personal injuries
(including illness), known or unknown, and damages to property, real or personal, caused
by, arising out of, or incurred during, my child’s (or my ward’s) attendance at the Camp,
including, without limitation, Claims caused by, arising out of, or incurred during
activities taking place off of the Camp’s premises and those caused by, arising out of, or
incurred during extended day care hours.
I intend, by my signature below, to bind myself and my heirs, personal representative,
successors and assigns.
Student Name:
_________________________
Parent/Guardian Name:
_________________________
Parent/Guardian Signature:
_________________________
Date:
_________________________
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Caravel Day Camp: 2014 Health Record
PART A: To be filled in by parent before physical examination
NAME:_________________________
PHONE NUMBER:
SEX: _________ BIRTHDATE: _____________
1st:_________________ 2nd: _______________
3rd:_______________
Illness and Health Problems: Check and give additional information if necessary.
Scarlet Fever
_____
Strep Throat
_____
Mentstrual Difficulties
_____
Depression
_____
Pneumonia
_____
Ear Infections
_____
Chicken Pox
_____
Frequent Colds
_____
Diabetes
_____
Measles
_____
Frequent Tonsillitis _____
Convulsive Disorders
_____
Rubella
_____
Hearing Difficulty
_____
Heart Trouble
_____
Mumps
_____
Speech Difficulty
_____
Orthopedic Difficulty
_____
Whooping Cough _____ Vision Difficulty
_____
Nephritis
_____
Rheumatic Fever _____ Allergies
_____
Learning Differences
_____
Tuberculosis
_____
EpiPen or EpiPen, Jr.
_____
Other
_____
_____ Asthma
ADD, ADHD
Nebulizer Treatments _____
Additional Information about your child (Include accidents, operations, etc.) Use back.
Immunization Dates: Please write in month, day, and year
DPT
Hib
Polio
Hep B
PPD
#1 __________
#1___________
#1 __________
#1 ________
Measles _________
#2 __________
#2___________
#2 __________
#2 ________
Mumps _________
#3 __________
#3___________
#3 __________
#3________
Rubella _________
#4 __________
#4___________
#4 __________
Varicella #1______
#5 __________
#2______
#5 __________
Other
_________
PART B: To be completed by examining physician. Please indicate condition by code and give details under
positive findings
Height: _____
Codes: No defect _____ Defect-correction or care not necessary _____
Weight: _____
Defect-care or correction necessary
_____
General Appearance
Scalp-Skin
_____
Teeth
_____
Lungs
_____
Blood Pressure _____
Eyes
_____
Neck
_____
Abdomen
_____
Urinalysis
_____
Ears
_____
Posture _____
Hernia
_____
Other
_____
Nose
_____
Glands _____
Extremities
_____
Throat
_____
Heart
Neurological _____
_____
Positive Findings: Include any pertinent history. Use back if necessary.
Recommendations: List any limitations. Use back if necessary.
Immunization given at this visit: _________________________________________________
MantouxTuberculin Skin Test
Date: ___________
Results: ___________
Physician’s Signature: _______________________________
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Date: __________________
2014 Medication Form
Please retain this form. Read carefully and return the signed and completed form
to the camp director when your child requires PRESCIPTION MEDICATION
during camp hours.
Examples:
1.
Antibiotics for infection
2.
Adderall/Ritalin for ADD, ADHD
3.
Insulin
4.
Albuterol Solution for Nebulizing, or inhaler
5.
Tylenol/ Aspirin
CAMPER’S NAME (PLEASE PRINT): __________________________________________
AGE: _______ yrs
________mos
DATE OF BIRTH:
__________________
ALLERGIES: __________________________________________________________________
MEDICATION TO BE GIVEN:
________________________________________________
STUDENT BEING TREATED FOR: ______________________________________________
LAST DOSE: _________________
TIME TO BE GIVEN: ______________________
SPECIAL INSTRUCTIONS:
______________________________________________________
I CAN BE REACHED AT:
______________________________________________________
NOTE: ALL MEDICATION’S MUST BE DELIVERED TO THE DIRECTOR UPON ARRIVAL TO
THE CAMP. IT MUST BE IN THE ORIGINAL CONTAINER WITH THE PHARMACY LABEL
INTACT AND CURRENT.
WHEN FILLING MEDICATIONS ASK THE PHARMACY FOR A
SCHOOL BOTTLE. THIS WILL ELIMINATE TRANSPORTING MEDICATONS ON A DAILY
BASIS.
I accept full responsibility for notifying the Director of any changes or difficulties that may develop while
dispensing this medication. I have provided the above named prescription medication in the original
container with the pharmacy label intact. I understand that failure to provide the above may result in the
medication not being given until clarification is obtained.
_____________________
____________________
Parent/Guardian Signature
Date
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