Summer Camp Check In

Camper Name

First Name

Last Name

Primary Contact for camper

First Name

Last Name

Relationship to camper

mother/father/guardian/nanny

Phone

(###)

###

####

Additional Emergency Contact (other than person listed above)

(###)

###

####

Relationship to camper

Does the camper have any food or environmental allergies.

Please list and explain.

Is the camper prescribed an inhaler?

Yes

If yes, please provide information on directions and use.

Please leave inhaler with a staff member. (Please be sure that it is labeled with camper name, and directions)

Is the camper prescribed an epipen?

YES

If yes, please provide information on directions and use.

Please leave epipen with a staff member. (Please be sure that it is labeled with camper name, and directions)

Please DO NOT enter the building if you or your child are sick. Children experiencing symptoms of illness will not be allowed to participate in class/camp.

Have you experienced any of the following symptoms in the past 48 hours:? • fever or chills • cough • shortness of breath or difficulty breathing • fatigue • muscle or body aches • headache • new loss of taste or smell • sore throat • congestion or runny nose • nausea or vomiting • diarrhea

Yes

If yes, please explain.

Who will be picking up the camper?

Please list name and phone number (if different from those listed above)

Any thing else we should know today?

Any injuries or issues that we should know about? Please let us know about any falls, scrapes, bruises, stitches or emotional concerns that would help us to better support your child.

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