One Child Health Form Parent or Guardian Name * First Name Last Name Email * 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 (###) ### #### Medical Insurance Provider * Policy Number of Insurance Provider * Medical Waiver By electronically signing this document below, I hereby verify that the below information is complete and accurate to my knowledge. I hereby grant permission for my child/children to receive first aid and emergency treatment by JumpIn NW Program personnel in the event of injury, or by the hospital emergency room, for a life-saving decision if I cannot immediately be reached. I voluntarily waive any claim against JumpIn NW personnel, or other persons transporting my child, against all liability, claims, damages, attorney fees, or expenses arising out of or in connection with any activities of the above-mentioned organization. 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 Sex Male Female Birthdate * MM DD YYYY Age 6 7 8 9 10 11 12 13 14 15 Camps Registered * Jump In All Day — July 15-17: ages 9-11 & 12-14 Day Campf 1 — July 9-11: ages 6-8 Choose One Free Merchandise * T-Shirt can only be ordered before June 1. 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 Blast Water Bottle T-shirt: Available only if submitting form before June 24 T-shirt Size Water Bottle Child S Child M Child L Adult S Adult M Adult L Adult XL 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 List any allergies and your child’s reaction to that allergy. If your camper will recquire medications administered during camp please list the medication, what it is for and what the dosage. All medications need to come to camp in their original bottle or packaging with the prescription label on the bottle or package and be given to the camp nurse each day. Administered drugs would also include Epipens and asthma inhalers. Please list medical, mental, or behavioral health issues that we should be aware of in order to safely care for your camper while attending Day Camps. These may include, Diabetes, Seizures, Asthma, Autism, or other health considerations. List 2 friends your camper may want to be with in an assigned group We do not place more than 3 requests together. Thank you!
