Multiple Camper Health Form

Parent or Guardian Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of 2nd Parent or Guardian

First Name

Last Name

Phone of 2nd Parent or Guardian

(###)

###

####

Emergency Contact *

If Parent cannot be reached

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

Photography Release *

If your child is in a photograph taken by Jump-In NW designated staff the photograph may be used in publications on-line or in print for advertising purposes.. Jump-In NW will not include the name of our campers on any publications or sell merchandise with your child's/children's photo. Jump-In NW will not share your child's/children photo with any business. It is for the exclusive use of Jump-In NW Camp publications and advertising. If you choose not to have your child allowed in publications they will not be in group photos when taken and will have a red circle on their tag so the photographer knows not to take photos of that child.

My Child may have photos taken that may or may not be included in Jump-In NW publications.

My child may not have photos taken by Jump-In NW

Name of Camper *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Camps Registered

Summer Blast Day Camp — July 9-11: Ages 6-8

JumpIn All Day — June 15-17-Ages 8-14

Choose 1 Free Merchandise *

T-Shirt can only be ordered before June 24. If you are registering after June 24 your camper will automatically receive a Water Bottle. If your camper would like a Water Bottle instead of a t-shirt please choose water bottle below. One T-shirt per camper before June 24 regardless of number of camps registered.

24 oz Stainless Steel Jump-In Summer Camp Water Bottle

T-Shirt: Only if Submitting Form Before June 24.

Swimming Ability *

Please Check All That Apply

Good swimmer

Ok swimmer

Struggling swimmer

Needs a life jacket to go in the pool

No Deep end unless in a life jacket

Cannot go in the deep end even with a life jacket

Will bring our own labeled life jacket

Tetanus is Current? *

Yes

No

Date of Last Tetanus *

MM

DD

YYYY

Camper #2

First Name

Last Name

Birthdate

MM

DD

YYYY

Camps Registered

Day Camp 1 — July 09-11: Ages 6-8

Jump-In All Day — July 25-28: Ages 8-14

Choose 1 Free Merchandise

T-Shirt can only be ordered before June 24. If you are registering after June 24 your camper will automatically receive a Water Bottle. If your camper would like a Water Bottle instead of a t-shirt please choose water bottle below. One T-shirt per camper before June 24 regardless of number of camps registered.

24 oz Stainless Steel Jump-In Summer Camp Water Bottle

T-Shirt: Only if Submitting Form Before June 15.

Tetanus is Current?

Yes

No

Last Date of Tetanus

MM

DD

YYYY

Swimming Ability

Please check all that apply

Good swimmer

Ok swimmer but doesn't need a life jacket

Struggling Swimmer

No deep end even with a life jacket

Needs a life jacket

Deep end only with a life jacket

I will bring a labeled life jacket for my child

Camper 3

First Name

Last Name

Birthdate

MM

DD

YYYY

Camps Registered

JumpIn All Day — July 15-17: Ages 8-15

Day Camp 1 — July 11-9: Ages 6-8

Choose 1 Free Merchandise

T-Shirt can only be ordered before June 24. If you are registering after June 24 your camper will automatically receive a Water Bottle. If your camper would like a Water Bottle instead of a t-shirt please choose water bottle below. One T-shirt per camper before June 24 regardless of number of camps registered.

24 oz Stainless Steel Jump-In Summer Camp Water Bottle

T-Shirt: Only if Submitting Form Before June 1st.

Tetanus is Current?

Yes

No

Date of Last Tetanus

MM

DD

YYYY

Choose 1 Free Merchandise

T-Shirt can only be ordered before June 15. If you are registering after June 1st your camper will automatically receive a Water Bottle. If your camper would like a Water Bottle instead of a t-shirt please choose water bottle below. One T-shirt per camper before June 15 regardless of number of camps registered.

24 oz Stainless Steel Jump-In Summer Camp Water Bottle

T-Shirt: Only if health form is submitted by June 15.