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Camp Webegee Medical Form

  1. EACH CAMPER MUST HAVE A MEDICAL FORM

    PLEASE FILL OUT THIS FORM COMPLETELY

  2. Session (check all that apply)*

  3. Camper's Information

  4. Sex:*

  5. Parent(s)/Guardian(s) with whom Camper Resides

  6. Emergency Contact

  7. Does the camper have any allergies? *

    If yes, list below:

  8. Is the camper taking any medication? *

    If yes, list below:

  9. Should the physical activity of the child be restricted for medical reasons?*

    If yes, list below

  10. Does your child have an Individualized Education Program (I.E.P.) provided by their school?*

    If yes, please contact Malory Smysor, Coordinator of Inclusive Services, at (314) 290-8507.

  11. Are you or your child in need of any special accommodations/assistance needs in order to successfully participate in our programs (e.g. an interpreter, etc.)?*

    If yes, please list below:

  12. *Please note: our staff will not be responsible for personal care e.g. toileting-including changing or feeding tubes.

  13. If you listed that your child needs assistance, please contact our Inclusion Coordinator, Malory Smysor (314) 290-8507.

  14. What is the level of your child’s swimming ability?*

  15. In case of an accident at the program, your permission is needed in order to allow your child to be treated quickly. Please sign the below statement in order to give that permission.

  16. MEDICAL EMERGENCY TRANSPORTATION & TREATMENT AUTHORIZATION

  17. In the event that my camper is injured or becomes ill and/or needs medical attention for any reason whatsoever and I (we) or the emergency contact cannot be contacted, this Authorization will serve as my request and authority for the camp supervisors to call a private ambulance service for the purpose of transporting my child to the hospital, doctor, or to the proper medical facility, and that I authorize any and all medical treatment provided to my (our) child. Please sign below.

  18. Please type your First and Last name

  19. FIELD TRIP PERMISSION RELEASE

  20. I hereby give permission for my camper to attend all Camp Webegee field trips/special events scheduled for the summer sessions that they are enrolled in. Please sign below.

  21. Please type your First and Last name

  22. PHOTOGRAPHIC RELEASE

  23. I hereby consent and authorize Webster Groves Parks and Recreation Department, the sponsor of this camp, to reproduce photographs or video taken of my child for advertising and publicity purposes of every description (such as in our program brochure). *

    If yes, please sign below

  24. Please type your First and Last name

  25. SPECIAL ARRANGEMENTS

  26. Special arrangements for your camper to arrive late or leave early can be accommodated with an advance written note; including time the camper needs to leave and who will be picking them up. If the person picking the camper up is not on the Sign In/Out sheet they will need to tell the Director or call Alison Edwards, Recreation Supervisor at the Rec Complex. Specific dates, please list dates below.

  27. AUTHORIZATION TO WALK OR RIDE TO/FROM CAMP

  28. My child has permission to walk to and from camp*

  29. My camper has permission to ride their bicycle to and from camp*

  30. My camper has permission to stay at the W.G. Aquatic Center on pool days (after Webegee exits the pool)*

  31. If you checked “yes” to stay at the pool, please indicate a day(s)

  32. SUBMIT ON OR BEFORE THE FIRST DAY OF CAMP; THE MED FORMS OF CAMPERS WITH SPECIAL NEEDS OR DISABILITIES SHOULD BE COMPLETED IMMEDIATELY UPON REGISTRATION (AT LEASE 2 WEEKS PRIOR TO THE START OF YOUR SESSION).

  33. Leave This Blank:

  34. This field is not part of the form submission.