Sewadar Name
*
First Name
Last Name
Camper Email Address
Gender
Age by Camp Start Date
Date of Birth
MM
DD
YYYY
Camper T-Shirt Size
Please select one size.
Diet Preference
Home Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Telephone
(###)
###
####
Mobile Number
(###)
###
####
Parental Email Address
Emergency Contact 1
First Name
Last Name
Contact's Relationship to Camper
Emergency Contact 1 Phone Number
(###)
###
####
Emergency Contact 2
First Name
Last Name
Contact's Relationship to Camper
Emergency Contact 2 Phone Number
(###)
###
####
Parental/Guardian Name and Signature
First Name
Last Name
Health Insurance Company
Address of Health Insurance Company
Health Insurance ID#
Health Insurance Policy Holder
First Name
Last Name
Policy Holder Relationship to Camper
UPDATED IMMUNIZATION RECORDS: MANDATORY- MUST EMAIL TO CAMPHIMMAT@GMAIL.COM FULL RECORDS PRIOR TO START OF CAMP
General Health Conditions and Medical History
Please obtain an updated immunization record (Tetanus/Diphtheria/Pertussis/Polio/Heamophilus Influenza B/Pneumococcal/HepB/HepA/MMR/Varicella) from your health care provider or school and email to camphimmat@gmail.com
Known Food and Medication Allergies
Please Select any that apply
Any Additional Medical History
Physical Limitations
Mental Health Conditions
Special Education Needs
Additional Health Considerations and Restrictions
Name of Family Physician
Family Physician Contact Number
(###)
###
####
Sunscreen & Bug Repellant Usage - Parental/Guardian Permission *
Self Application of Sunscreen and Bug Repellant: I give permission for the applicant to carry and self apply sunscreen and bug repellant. I understand that the following conditions must be met in order to promote proper and safe use of sunscreen and bug repellant at Camp Himmat.
Assisted Application: If the applicant is unable to apply the sunscreen and/or bug repellant themselves, I give permission for camp staff to assist with the application of the sunscreen and/or bug repellant. Reminder: Sunscreen and bug repellants are considered drugs and shall be checked and logged by the camp as such in accordance with the policies and procedures set forth in their safety plan.
Parental/Guardian Signature regarding Sunscreen Application
First Name
Last Name
Meningococcal Meningitis Vaccination Response Form
Meningococcal Meningitis Vaccination Response Form
New York State Public Health Law requires that a parent or guardian of campers who attend an overnight children's camp for seven (7) or more consecutive nights must answer the following questions.
*If your child received the meningococcal vaccine before February 2005 called Menomume, please note this vaccines protection lasts for approximately 3 to 5 years. Revaccination with the new conjugate called Menactra should be considered within 3 to 5 years after receiving Menomune.
Parental/Guardian Signature regarding Meningococcal Meningitis Vaccination
First Name
Last Name
Additional Activities
I give permission for the camper to participate in all of the following
Media Release
I do hereby grant or deny permission to use the image of my child as marked by the selections below. Such use includes the display, the distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures, newsletters, videos, and digital images such as those on the website.
Parental/Guardian Signature regarding Media Release
First Name
Last Name
Indemnification/Waiver of Liability *
*
Camper Name
First Name
Last Name
Parental/Guardian Signature for Indemnification/Waiver of Liability
First Name
Last Name
Date of Signature
MM
DD
YYYY
