First Name
Last Name
Preferred Name
SexMaleFemaleOther
Date of Birth
Age
Address
City
Zip Code
Primary Phone CellHomeWork
Secondary Phone
CellHomeWork
Participant's T-shirt Size YSYMYLSMLXLXXLXXXL
First Contact Name
Relationship
Primary Phone
Second Contact Name
Have allergic reactions,including allergies to food or environmental? YesNo
If so, what are those reactions and the protocol?
Wear glasses/contact lenses? YesNo
Use a wheelchair? YesNo
Crutches? YesNo
Walker? YesNo
Is the participant verbal? YesNo
Use a communication device? YesNo
If so, please list what system or app is being used?
Have emotional upsets? YesNoSometimes
If yes, what usually triggers emotional upsets?
What normally calms down the participant, if they become upset?
Have physical limitations YesNoSometimes
Typical camp activities include dancing, sports, games, cooking, arts and crafts, walking activities, and more. Please describe or attach any instructions or precautions that should be taken during routine camp activities.
Medication Name
Total Dosage per Administration
Total # of Pills per Administration
Special Instructions
Specific Times to Administer (ex. 9am, 2:30pm, etc.)
To be Given During Camp Hours?
—Please choose an option—YesNo
It is agreed that Signal Centers assumes no responsibility for the participant’s personal property and is released from liability in connection with camping activities and medication administration, except as covered by the participant’s insurance. I understand my participant will be outside participating in various recreational activities.
Parent/Guardian's Printed Name
Date
Permission is hereby granted for official representatives of Signal Centers and the business or individuals it designates to photograph my child, while participating in the 2021 Camps at Signal Centers. These photos will be used for the sole purpose of promoting, reporting, or publicizing the work and programs of Signal Centers. Such promotion may include the use of my participant’s name and picture in newspaper or other print media/promotions, DVDs, television news, and/or the Agency’s website. I also give my permission for observations of my child to be conducted and research and statistical data collected, so long as confidentiality of information is maintained.
YesNo
Participant's Name
Print Parent/Guardian's Name
Copy of Insurance Card Front
Copy of Insurance Card Back
