2017 Camp Clarita Health History Form

PARTICIPANT INFORMATION

Last Name

First Name

Age

Gender:
MaleFemale

Date of Birth

Parent/guardian email address

Address

City

Zip Code

Home Phone


PARENT/GUARDIAN INFORMATION: AUTHORIZED TO PICK UP AND OBTAIN/CHANGE REGISTRATION INFORMATION

Father/Guardian

  Address is the same as participant.

Full Name

Work Phone

Cell Phone

Home Phone

Address

City

Zip Code

Mother/Guardian

  Address is the same as participant.

Full Name

Work Phone

Cell Phone

Home Phone

Address

City

Zip Code


PROGRAM INFORMATION

Camp Program
Wee FolksLittle FolksJunior AdventuresRanger CampExplorer CampVoyager Camp

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


EMERGENCY CONTACT AND PERSONS AUTHORIZED TO PICK UP MY CHILD (other than parents, must be at least 16 years of age)

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone


SWIM ABILITIES FOR RANGER, EXPLORER, AND VOYAGER CAMPERS: (check one only)


HEALTH INFORMATION

The information you provide here will be held in the strictest confidence. It will be kept on file in our binder or carried by the camp director on field trips.

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.

INSURANCE INFORMATION

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.


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