Columbia Springs · Autumn Camp 2020

Camper Information

Camper's Name

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First Name

Last Name

Camper's Date of Birth

*

(mm/dd/yyyy)

Camper's Gender:

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Camper's grade level in fall 2020?

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Contact Information

Guardian's Name

*

First Name

Last Name

Relationship to Camper:

*

Email

*

Verify Email

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Cell Phone

*

Home Phone

Work Phone

Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Are you (the guardian) the primary emergency contact?

*

In an emergency, the primary emergency contact is:

*

First Name

Last Name

Relationship to Camper

*

Emergency Contact's CELL number

*

Emergency Contact's HOME number

Emergency Contact's WORK number

Secondary Emergency Contact

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First Name

Last Name

Relationship to Camper

*

Secondary Contact's CELL number

*

Secondary Contact's HOME number

Secondary Contact's WORK number

Including yourself, please list the first and last name of each person authorized to pick your child up from Columbia Springs.

*

What school does this camper attend?

*

Does your child have a friend or sibling they would like to be paired with if possible?

(Sessions are generally divided by grade level)

Has your child attended camp at Columbia Springs in the past?

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If so, please tell us the year your child attended and the name of their group leader(s).

Please describe any special needs that we should be aware of (fears, behaviors, etc.):

Does your child require the assistance of a para-educator during the school year?

*

Please let us know how you plan to accommodate their learning needs (para-educator present, etc).

*

Has your child been tested and diagnosed for a food allergy by a health care professional?

*

If NO, are there any food sensitivities or preferences you'd like us to know about:

If YES** please list food allergies below:

*

Please list any physical/medical conditions that would be helpful for us to know about your child (recent injuries, allergies, etc.):

Does your child have any conditions that may make them particularly vulnerable to COVID-19 such as asthma, a heart condition or diabetes?

Please list all current medications, including over-the-counter medications:

It is expected that your child arrive for camp prepared to spend the day outdoors. This includes wearing sunscreen. If your child arrives without sunscreen, is it OK for a staff member to provide/assist with sunscreen application?

*

Other Comments?

"I certify that my child will have health insurance coverage during camp, and I give full consent for my child to receive the medical treatment deemed necessary by those responsible."

*

Reasonable attempts will be made to inform legal guardians in case medical treatment is required.

Insurance Company

*

Policy / Group/ ID Number(s)

*

Photo Release

*

I agree that any photographs or digital images taken by Columbia Springs personnel of my child as a program participant, and copies of artwork made by my child while a Columbia Springs program participant, shall be the property of Columbia Springs, and may be used by Columbia Springs, at its discretion, for any publicity, education, marketing and/or advertising purposes. I hereby consent to and authorize such use without restriction.

Would you like to be added to the Columbia Springs' mailing list?

*

How did you very first hear about this program ?

*

Please tell us how you heard about camp!

Payment

You will be redirected to a payment page after submitting this form.

Confirm registration	Quantity
$125 - Session 1: Sept 28- Oct 2nd (4th & 5th Graders)

	Quantity
$125 - Session 2: Oct 12 - 16th (2nd & 3rd graders)