Columbia Springs · 2021 Summer Nature Day Camp Session 1

Camper Information

Camper's Name

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First Name

Last Name

Camper's Gender:

*

What grade is this camper entering in the upcoming academic year?

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Camper's Date of Birth

*

(mm/dd/yyyy)

What school does this camper attend?

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Does your child have a friend or sibling they would like to attend camp with?

(Sessions are generally limited to similarly aged campers)

Camper tee-shirt size

*

Contact Information

Guardian's Name

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First Name

Last Name

Relationship to Camper:

*

Email

*

Verify Email

*

Cell Phone

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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 camp.

*

Camper Details

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

*

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?

*

Is there anything else you'd like us to know?

"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)

*

Health and Safety Agreement

*

I am aware of the current risks associated with the COVID-19 pandemic and that the situation is constantly changing. I know it is my responsibility to stay up to date on the latest risks and that I am required to monitor my camper for signs and symptoms related to COVID-19 during the 2 weeks prior to camp and the 5 days my child is attending camp, as outlined in the Columbia Springs Summer Day Camp Health and Safety Policy linked below. If anyone in our household becomes ill or is exposed to the COVID-19 virus, my child will not attend this camp and I will e-mail or call Columbia Springs to cancel. I understand that I am eligible for a refund of program fees minus the credit card charges. I agree to familiarize my camper with the guidelines that Columbia Springs will expect them to follow during camp before they arrive to participate. https://drive.google.com/drive/u/1/folders/120U5lw4C0vF0s0qBf3IMCGsOFCssraTT

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?

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How did you very first hear about our Summer Nature Camp?

*

Please tell us how you heard about camp!

Payment

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

Session 1	Quantity
$180 - Summer Nature Day Camp