Camper Information

Little Yellowjackets Summer Camp

Registration Form

Child's Name _________________ _ DOB ____ _ Age __ First Last

Mailing Address ____________________ _ Gender LJM UF

Camper has permission to participate in free swim if they choose: D Yes O No

Campus has permission to participate in ropes and climbing activities if they choose LJYes O No

Camper Shirt Size: Dvs DvM DvL Adult: Os -□M DL OxL

How did you hear about this camp? _______________________ _

Parent/Guardian Information

Parent 1 ______________ _ Parent 2 _____________ _

Contact# _____________ _ Contact# _____________ _

Email _______________ _ Email ______________ _

Who should we contact first? 0 Parent 1 D Parent 2 0 Other: __________ _

Emergency Contacts

Please list two non-parent contacts

(1) Name _____________ _ Relationship _________ _ Contact # _____________ _

(2) Name _____________ _ Relationship _________ _ Contact # _____________ _

Camper Release Authorization

Please list persons (other than parents and emergency contacts) who HAVE permission to pick up your child (name and phone)

*Parents, emergency contacts, and the individuals listed above are the only individuals permitted to pick up your child from camp. If an individual is not on this list, they will not be allowed to pick up your child. Any additional or deletions to this list must be done in person. ANYONE PICKING UP YOUR CHILD MUST SHOW A DRIVERS LICENSE.*

Please list anyone WHO DOES NOT have permission to pick up your child

Medical Information

Please list any issues we should know about __________________________ _

Physician's Name _______________ _ Phone ____________ _

University of Wisconsin -

2020 Youth Event Health Form

Event Name: Dates:

Youth Name: Bi11h date �-'- Age on I" day of event ___ Sex:OMalcOernale------------

Custodial Parent/Guardian (or spouse) E-mail address: ----------------

Phone Numbers: Home ( __ ,__ ___ _ Work( ___ .._. ___ _ Cell phone ( ______ _

Home address:-------------·----------------------------Street City State

Second parent/guardian and/or emergency contact: ____________________ Phone: Home <.--�,'----

Work ( _____ _ Address:

Street City State

CONSENT FOR MEDICATION ADMINISTRATION AND MEDICAL TREATMENT

IQ THE-PARENT(S) QR LEGAL GUARDIAN:

If your son, daughter, or ward will be under the age of 18 while at the University of Wisconsin - , it is event/camp policy to secure your consent for m edicatio11 distribution and for the use of medical devices. The medication or mediq1I device must be administered by designated event/camp health staff with the exception that a limited amount of medication for Jife-thriatening conditions may be carried by my son/daughter/ward (i.e. bee sting kit, inhaler, insulin syringe).

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Prescription mcdication(s) has been brought to event/camp. All prescription medication must be in theoriginal medicine bottle (sec picture at right) and labeled with the youth participant's name, doctor's name, medication name, dosage, prescription number, date prescribed, and instructions. Also, information about any prescription medications must be provided in writing to event/camp health staff with the infonnation requested on the second page of this form.

Over-the-counter medications have been brought to event/camp and may be administered by camp health staff as needed. All over-the-counter medications must be labeled with the youth participant's name, medication name, dosage, and instruction.

D No medication(s) has been brought to event/camp.

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If your son, daughter, or ward will be under the age of 18 years while at the event/camp, it is our policy to secure your agreement to all of the following statements. By signing below:

• I am giving my consent in advance for medical treatment at an appropriate medicnl facility in case of illness or injury.

• I am stating that I am aware of and accept the risk inhernnt in the program activity.

• l attest that all information on both sides of this form is correct and up-to-date, and that I will provide 11ny and all significant,material, or important changes to any information in this fom1 to event/camp staff no later than check-in.

• I agree to hold harmless and indemnify the Board of Regents of the University of Wisconsin System, and the University of Wisconsin - , their officers, agents, and employees from any und ull liubility, loss, damages, costs, or expenses which are sustained, ineun-ed or required arising out of the actions of my son, daughter or ward in the course of the event/camp.

Particip1111t Name (Please Print)

SIGNATURE OF PARENT OR LEGAL GUARDIAN Date

(Must complete reverse side)

uw Participant Name: _______________ _

Youth Event Health Form (Continued) Parent/Guardian Signature: ____________ _

Health Conditions (check)

D Asthma Diabetes Epilepsy Psychiatric Cognitive/Developmental

Al(ergies (check & list specifics)

□ Insect stingsFoodsMedications

D Other

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Any dizziness, light-headedness or fainting associated with exercise within the past year

Any unexplained, rapid or irregular heart beat within the past year

A physician has sometime denied or restricted participation in sports due to a heart problem

Donny allergies require an EPIPEN Injection?□ Ye1-LlNo Is an inhaler required and carried by youth?Ues CT, Date of last Tetanus booster:

Name of Insurance Co.: ______________ Policy II:

Description of any limitation or restriction of event activities:

Any special accommodations regarding physical or emotional conditions that we need to be aware of regarding your child's participation in this event/camp (include circumstances when physician should be notified)?

Medications camper will be taking at camp:

Name of Medication Reason Dosage (mg) Times of day given Prescribing Physician & Phone Number

l. Does the youth experience any side effects from the medication? (i.e., mood/behavior changes, upset stomach, D Yes D Nodia1Thea)

List any special instructions or additional information regarding the medication that would be helpful to the Health Care staff: 2.

*** FOR EVENT/CAMP USE ONLY.:. TO BE COMPLETED BY HEAL TH CARE STAFF AT CHECK-IN

I. Are there w1y changes in your child's healtl1 status since the medicnl fom1s were sent in? 0 No O Yes

2. Has yow· child, or anyone in your family heen sick or exposed to w1y communicable disease in the [)HSI month? 0 No O Yes

3. Does your child now lrnve any roshcs or open sores? D No O Yes

4, Arc there any cho11ges in )'UUJ' dependent's medications'/ ((/'!'es, S1a_(f111ake cha11ges. & sign/ □ No O Yes

5. Docs your child hove an)' rc<:<:ut injury or activity restrictions? □ No O Y cs

<,, Will the custodinl roretll(s) or guurdinn he m·ailnblc 01 the numbers listed 011 this form during the cnmping session? □ No D Yes

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If NO, list lht! nnme & phone number of pcrson(s) authorized to make decisions on their hehnlr if ditkrenl than tl1c cmcrgcncy contact listed on the reverse side of this form:

---·-------------------------In formalinn 1>ro,·iclcd 11,·: To: llntc: