Kids' Adventure Club 2017 Camper Information
Please complete this form ONE PER CHILD
Kids’ Adventure Club 2017 Camper Information Child’s Full Name:___________________________________________ Age:_____________________ Entering Grade:_______________________________ Gender: M F Date of Birth:_________________ Any known allergies? Yes___ No___ Allergic to:______________________________________________ Reaction:________________________________________________________________________________ ________________________________________________________________________________________ Mini Camp Ages 3-4
Yampa Camper Ages 5-1st Grade
Routt Scout 2nd & 3rd Grade
Pioneer 4th Grade – Age 14
PLEASE MARK THE DAYS THAT YOU WOULD LIKE YOUR CHILD TO ATTEND:
M
T
June W
Th
F
July W
Th
F
4 No Camp
5
6
7
10
11
12
13
14
M
T
3
M
T
August W Th
F
1
2
3
4
7
8
9
10
11
15
16
17
18
12
13
14
15
16
17
18
19
20
21
14
19
20
21
22
23
24
25
26
27
28
21
26
27
28
29
30
31
Total # of Days:________________ NEW lemon yellow T-shirts this year! Camp T-shirt @ $15 each:
Quantity: __________
Size (Please Circle)
2-4
6-8
10-12
14-16
Child Profile Is there anything special (ex. Behavioral concerns or control methods, dietary restrictions, etc.) that we need to know about your child that would assist us in providing him/her the best care? ________________________________________________________________________________________ ________________________________________________________________________________________ Child’s General Health Does your child require any special attention, routines, or medication that may have to be taken into consideration in planning for his/her time at camp? ________________________________________________________________________________________ ________________________________________________________________________________________ Please complete this form ONE PER CHILD
Kids’ Adventure Club 2016 Health Care Summary –Mini Campers Only *To be completed by child’s physician* Please have child’s physician complete this form and return to KAC on or before the child’s for day of camp. Name of Child:_______________________________________________________DOB:______________ Address:______________________________________________________Phone:___________________ Parent/s or Guardian:____________________________________________________________________ Date of last physical exam:______________________ How long have you been seeing this child?___________________________________________________ How frequently do you see this child when he/she is not ill?_____________________________________ Does this child have any allergies? (Please include allergy medication.)___________________________________________________________________________ _____________________________________________________________________________________ Reaction:_______________________________________________________________________ Is a modified diet necessary? Yes___ No___ Details:___________________________________________ Does this child have any condition that might result in a emergency? Yes___ No___ Details:________________________________________________________________________ What is the status of the child’s vision?_____________________________________________________ hearing?___________________________________________________ speech?____________________________________________________ Please list below any important health problems. Indicate if you or someone else is following the child for the problem and check which problems require special attention at the center: Health/Development Concern:____________________________________________________________ Followed by:_________________________________ Requires Special Attention:___________________ Health/Developmental Concern:___________________________________________________________ Followed by:_________________________________ Requires Special Attention:___________________ Other information helpful to the Kids’ Adventure Club: _____________________________________________________________________________________ _____________________________________________________________________________________
Physicians’ Signiature:__________________________________________________Date:_____________ Physician’s Print Name:__________________________________________________________________ Clinic:___________________________________________________ Phone:_______________________ Address:______________________________________________________________________________ Please include immunization records with the health care summary. Thank you.
Kids’ Adventure Club 2017 Camper Information Child’s Full Name:___________________________________________ Age:_____________________ Entering Grade:_______________________________ Gender: M F Date of Birth:_________________ Any known allergies? Yes___ No___ Allergic to:______________________________________________ Reaction:________________________________________________________________________________ ________________________________________________________________________________________ Mini Camp Ages 3-4
Yampa Camper Ages 5-1st Grade
Routt Scout 2nd & 3rd Grade
Pioneer 4th Grade – Age 14
PLEASE MARK THE DAYS THAT YOU WOULD LIKE YOUR CHILD TO ATTEND:
M
T
June W
Th
F
July W
Th
F
4 No Camp
5
6
7
10
11
12
13
14
M
T
3
M
T
August W Th
F
1
2
3
4
7
8
9
10
11
15
16
17
18
12
13
14
15
16
17
18
19
20
21
14
19
20
21
22
23
24
25
26
27
28
21
26
27
28
29
30
31
Total # of Days:________________ NEW lemon yellow T-shirts this year! Camp T-shirt @ $15 each:
Quantity: __________
Size (Please Circle)
2-4
6-8
10-12
14-16
Child Profile Is there anything special (ex. Behavioral concerns or control methods, dietary restrictions, etc.) that we need to know about your child that would assist us in providing him/her the best care? ________________________________________________________________________________________ ________________________________________________________________________________________ Child’s General Health Does your child require any special attention, routines, or medication that may have to be taken into consideration in planning for his/her time at camp? ________________________________________________________________________________________ ________________________________________________________________________________________ Please complete this form ONE PER CHILD
Kids’ Adventure Club 2016 Health Care Summary –Mini Campers Only *To be completed by child’s physician* Please have child’s physician complete this form and return to KAC on or before the child’s for day of camp. Name of Child:_______________________________________________________DOB:______________ Address:______________________________________________________Phone:___________________ Parent/s or Guardian:____________________________________________________________________ Date of last physical exam:______________________ How long have you been seeing this child?___________________________________________________ How frequently do you see this child when he/she is not ill?_____________________________________ Does this child have any allergies? (Please include allergy medication.)___________________________________________________________________________ _____________________________________________________________________________________ Reaction:_______________________________________________________________________ Is a modified diet necessary? Yes___ No___ Details:___________________________________________ Does this child have any condition that might result in a emergency? Yes___ No___ Details:________________________________________________________________________ What is the status of the child’s vision?_____________________________________________________ hearing?___________________________________________________ speech?____________________________________________________ Please list below any important health problems. Indicate if you or someone else is following the child for the problem and check which problems require special attention at the center: Health/Development Concern:____________________________________________________________ Followed by:_________________________________ Requires Special Attention:___________________ Health/Developmental Concern:___________________________________________________________ Followed by:_________________________________ Requires Special Attention:___________________ Other information helpful to the Kids’ Adventure Club: _____________________________________________________________________________________ _____________________________________________________________________________________
Physicians’ Signiature:__________________________________________________Date:_____________ Physician’s Print Name:__________________________________________________________________ Clinic:___________________________________________________ Phone:_______________________ Address:______________________________________________________________________________ Please include immunization records with the health care summary. Thank you.
