2017 Camp Clarita Health History Form

Last Name

First Name

Age

Gender:
MaleFemale

Date of Birth

Parent/guardian email address

Address

City

Zip Code

Home Phone

Full Name

Work Phone

Cell Phone

Home Phone

Address

City

Zip Code

Full Name

Work Phone

Cell Phone

Home Phone

Address

City

Zip Code

Camp Program
Wee FolksLittle FolksJunior AdventuresRanger CampExplorer CampVoyager Camp

Camp Location
Canyon Country ParkNewhall ParkNorth Oaks ParkSanta Clarita ParkValencia Glen ParkValencia Meadows Park

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Wee Folks, Little Folks and Junior Adventures N/ARequires life vest (parents may need to provide)Not a strong swimmer but can touch in shallow water. No life vest requiredModerate swim ability/taken some swim lessonsFully able to swim and may take swim test with lifeguards in order to swim in deep water and jump off diving board

Name of Physician

Address

Phone

Allergies
YesNo

If yes, please list the allergies and describe the severity of the reaction (medication, seasonal, food, etc.)

If your child has any special need that requires specific accommodations so your child can fully enjoy camp, please contact Inclusion Services
at (661) 290-2296, or inclusionservices@santa-clarita.com. To ensure appropriate accommodations, please request inclusion services a
minimum of two weeks in advance.

Will your child need to take medication while at camp? YesNo
Any medication dispensed to your child must be brought to camp in its original prescription container and a separate form must be completed.

Carrier/Plan Name

Group #

Name of Insured

Address

Phone

Relationship to Camper

*We reserve the right to request proof of age at any time.

PERMISSION TO PARTICIPATE/CAMP POLICIES AND PROCEDURES

I have the authority and voluntarily agree for my child to participate in City operated activities or programs, or any extension thereof.

I hereby waive, release, and hold harmless from any liability or claims for damages for personal injury, including death, as well as from claims or property damage which may arise in connection with such activities or programs, against the Supervisors, City of Santa Clarita, and its elected and appointed officials, agents, and employees. As a parent/guardian, I hereby consent to treatment of my minor child for any and all medical procedures deemed necessary as a result of accident or injury. I further agree to pay any and all costs incurred as a result of said treatment. I hereby give permission to the City of Santa Clarita to use my child(ren)’s photographs as they see fit for promotional purposes. I understand the photographs belong to the City and I will not receive payment of any kind.

An original signature is also required, therefore, you will be asked to sign this form on your child's first day of camp.