stem academy

CAMPER health, pickup, and
AGREEMENT FORM

Camper's Name

Parent/Guardian Name

Emergency Contact

Emergency Contact Name (Other Than Parent/Guardian)

Emergency Contacts' Relationship To The Camper

Emergency Contact Phone Number

Pickup Authorization

Authorized Person's Name (Other Than Parent/Guardian)

Authorized Person's Relationship To The Camper

Authorized Person's Phone Number

Authorized Person's Name (Other Than Parent/Guardian)

Authorized Person's Relationship To The Camper

Authorized Person's Phone Number

Health Information

Physician's Name

Physician's Phone Number

Are there any health problems including medication, allergy, physical, psychiatric, or behavioral of which we need to be aware?

Yes

Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child's camp experience is positive?

Yes

Please Note: If the answer is yes, additional forms may be required.

Immunization Information

For campers who currently reside within the United States, a United States territory, or the District of Columbia: Does the camper have any immunization exemptions because of a parental or guardian objection or medical contraindication?

Yes (List Below)

For campers who reside outside the United States, a United States territory, or the District of Columbia: Attach record of vaccination or immunity on Department form MDH-896.

Attach File Here...

Sunscreen Authorization

Protecting campers from harmful UV rays is a top priority. Sunscreen is an essential part of our outdoor activities, this ensures all campers are properly protected throughout the day. If you wish for your child to apply sunscreen while at camp the sunscreen must be labeled with camper’s name and be in the original container. Please note that CITS STEM CAMP does not provide sunscreen.

Please Choose From The List Below

Option 1: No Sunscreen

Option 2: Self-Application (If your child is comfortable and capable of applying sunscreen independently, this is the method we encourage.)

Option 3: Camp Staff Assistance With Application: (If your child needs help applying sunscreen, please complete the following information to authorize camp staff to assist them with sunscreen application during camp activities. Please send in "spray-on" sunscreen. Camp Staff will spray on the sunscreen and camper will then be responsible for rubbing in the sunscreen.)

Acknowledgement of Policies, Risk,

and Release of Liability

By signing below the camper's parent/guardian agrees that they have read and agree to the 2024 Camp Policies and agree to release Computer Island Technology Services LLC, its staff, volunteers, partner and sponsors from any and all liability arising from:

Injuries, illnesses, or accidents sustained by the participant while participating in camp activities.
Loss or damage to the participant's personal belongings.
Any other claims, demands, or causes of action arising out of the participant's participation in the camp program.

Signature

Signature field is empty.

Date

Parent/Guardian Signature

I hereby declare that the information I have provided above is true and correct to the best of my knowledge.