NYBG Science Camp Emergency/Health History Form

Please give us your emergency contact and carpool information below. Agreement to the code of conduct listed below is required. Required fields are marked with an asterisk (*).

EMERGENCY MEDICAL INFORMATION AND AUTHORIZATIONS

Today's Date 12/05/2016
Child's Name:
*First Name
*Last Name
*Birth Date
*Grade
My child is enrolled in-please check appropriate box(es):*

Winter Science Camp: Plant Pioneers (2/16-2/20)
Spring Science Camp: Wonders of Spring (4/6-4/10)

Summer Science Camp Session 1
Art in Nature Camp (7/13-7/17)
Forest Adventure Camp (7/20-7/24)
Wild Wetlands Camp (7/27-7/31)

Summer Science Camp Session 2
Art in Nature Camp (8/10-8/14)
Forest Adventure Camp (8/17-8/21)
Wild Wetlands Camp (8/24-8/28)
Person to Contact in an Emergency*:
*Name
*Relationship
*Home Phone
*Cell Phone:
*Work Phone:
Alternate Emergency Contact*:
*Name
*Relationship
*Home Phone
*Cell Phone:
*Work Phone:

Emergency Authorizations

IMPORTANT: Please describe any special health considerations including, but not limited to, allergies, physical or behavioral conditions that may affect your child's participation in this camp in the section below.

What allergies does your child have? Please be specific as to the severity and treatment. If none, indicate "none" in the field below*:
Please list all of your child's current medications (both prescribed and over-the-counter)*:
Please describe any physical, mental, behavioral, or psychological conditions requiring medication, treatment, or for which your child is under the care of a doctor or health practitioner, if you would like us to be aware of them*:
Limitations (including dietary restrictions)*:
Behaviors of which staff should be aware, and how you or your child’s school handle this behavior*:
Is there any additional information you can provide to ensure a positive camp experience for your child?:

NYBG SCIENCE CAMP CARPOOL/PICK-UP AUTHORIZATIONS

The following individuals are authorized to pick up my child from camp:

Name
Relationship
Cell Phone
Day Phone:

Name
Relationship
Cell Phone
Day Phone:

Name
Relationship
Cell Phone
Day Phone:

Name
Relationship
Cell Phone
Day Phone:

NOTE: Written notification by parents or guardian MUST be given for pick-up by someone other than persons listed. If your carpool changes before your child's camp session, complete a new form. Please let us know in advance if there are any issues regarding pick-up/drop-off of which we should be aware (custody disputes, etc.).

CAMPER CODE OF CONDUCT
• Campers will treat their fellow campers, instructors, and volunteers with respect.
• Campers will follow directions and stay with their group.

Please read and discuss these expectations with your child. In the event that a camper does not follow the Code of Conduct, or his or her behavior endangers other campers or interferes with an instructor's ability to provide programming, the instructor will inform the parent and the Coordinator of Camp Programs at pick-up or through a phone call. If a second incident occurs, parents may be asked to withdraw from camp. Refunds will not be given for behavior-related withdrawals.

I have read and discussed this Code of Conduct with my child. (Please check box.)*

I understand that by completing and submitting this Medical Form via electronic transmission that I acknowledge the above statements and my submission of this form on-line shall substitute for and have the same legal effect as an original form signature.

By registering for NYBG Science Camp, I agree to the terms and conditions as outlined in the Camp Guidelines.