2024 Medical Information and Emergency FormTo complete our enrollment process, all registrants must fill out and submit a Medical Information and Emergency Form for each family.* = Required FieldsParent or Guardian's Full Name* First Last Email Address*Please use the email address that you submitted for registration. How many campers do you have?*123Home Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Regular PhysicianRegular Physican's Name* First Last Physican's Phone*Medical Information for Child #1Name First Last Child #1 Age:Does Child #1 have any medical conditions?*Please select oneYesNoMedical ConditionsPlease list medical conditions for Child #1 (asthma, diabetes, epilepsy, etc.)Click on + to add multiple conditions. Does Child #1 have any allergies or allergic reactions to medications?*Please select oneYesNoAllergies and allergic reactions to medications*Please list Child #1's allergies and include any allergic reactions to medications.Click on + to add multiple conditions.Allergy ItemAllergic Reaction Is Child #1 currently taking medications?*Please select oneYesNoMedicationsPlease list your child's medications.Click on + to add multiple conditions. Well-Camper InformationPlease describe any additional medical, behavioral, social/emotional support needs that we should be aware of in order to assist your child in having the best possible camp experience:Insurance Details*Insurance CompanyMedical NumberMedical Information for Child #2Name First Last Child #2 AgeDoes Child #2 have any medical conditions?*Please select oneYesNoMedical ConditionsPlease list medical conditions for Child #2 (asthma, diabetes, epilepsy, etc.)Click on + to add multiple conditions. Does Child #2 have any allergies or allergic reactions to medications?*Please select oneYesNoAllergies and allergic reactions to medications*Please list Child #2's allergies and include any allergic reactions to medications.Click on + to add multiple conditions.Allergy ItemAllergic Reaction Is Child #2 currently taking medications?*Please select oneYesNoMedicationsPlease list your child's medications.Click on + to add multiple conditions. Well-Camper InformationPlease describe any additional medical, behavioral, social/emotional support needs that we should be aware of in order to assist your child in having the best possible camp experience:Insurance Details*Insurance CompanyMedical NumberMedical Information for Child #3Name First Last Child #3 AgeDoes Child #3 have any medical conditions?*Please select oneYesNoMedical ConditionsPlease list medical conditions for Child #3 (asthma, diabetes, epilepsy, etc.)Click on + to add multiple conditions. Does Child #3 have any allergies or allergic reactions to medications?*Please select oneYesNoAllergies and allergic reactions to medications*Please list Child #3's allergies and include any allergic reactions to medications.Click on + to add multiple conditions.Allergy ItemAllergic Reaction Is Child #3 currently taking medications?*Please select oneYesNoMedicationsPlease list your child's medications.Click on + to add multiple conditions. Well-Camper InformationPlease describe any additional medical, behavioral, social/emotional support needs that we should be aware of in order to assist your child in having the best possible camp experience:Insurance Details*Insurance CompanyMedical NumberEmergency ContactsFirst Parent's Name* First Last First Parent's Phone*Please include the area code and format your phone numbers as (555) 555-5555.Daytime NumberEvening NumberSecond Parent's Name First Last Second Parent's Phone*Please include the area code and format your phone numbers as (555) 555-5555.Daytime NumberEvening NumberOther Contact's Name* First Last Other Contact's Phone*Please include the area code and format your phone numbers as (555) 555-5555.Daytime NumberEvening NumberOther Contact's Relationship to You (friend, neighbor, coworker, etc.)Authorized AdultsCanyon Camp requires that all children be signed in and out by an authorized adult. Please list the adults authorized to sign you child in and out (other than Emergency Contacts listed above) Authorization for Emergency Medical TreatmentConsent*This information will be kept in the possession of Canyon Arts & Creeks Camp. A copy will be distributed to the person in charge of each activity in which the student/minor participates. Should the need arise this information will be given to the proper medical authorities. I understand that in the case of illness or injury to my child, Canyon Arts & Creeks Camp will try to notify me, or the person I have listed above as an emergency contact. In case of medical emergency concerning my child, at a time when I or my listed emergency contact cannot be notified, I grant full power to the Canyon Arts & Creeks Camp to 1) arrange for the transportation of my child, whether by ambulance or otherwise, to a proper facility where emergency medical treatment would normally be administered, including but not limited to, an emergency room of a hospital, a doctor’s office, or a medical clinic; and 2) sign releases as may be required in order to obtain any medical or surgical treatment as is required in the judgment of medical authorities at the facility. I agreeCOVID-19 Participation Agreement and WaiverConsent*I acknowledge that Canyon Arts & Creeks Camp has adopted preventative measures informed by the CDC, Contra Costa Health Department, and Canyon School District to reduce the spread of COVID-19, and I must comply with all set procedures to reduce the spread while my child is attending camp. I understand the contagious nature of COVID-19, and acknowledge that Canyon Arts & Creeks Camp can not guarantee that my child will not become infected with the COVID-19 while attending camp. I voluntarily seek services provided by Canyon Arts & Creeks Camp and assume the risks described above with my child being enrolled at camp. I attest that: * My child will not attend camp if they are experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat, fatigue, congestion, runny nose, nausea, vomiting, diarrhea, or new loss of taste or smell. * My child will not attend camp if I believe they have been exposed to someone with a suspected and/or confirmed case of COVID-19. * My child will not attend camp if they have tested positive for COVID-19 and not yet cleared as non contagious by state or local public health authorities. * I am following all CDC recommended guidelines as much as possible and limiting my exposure to the COVID-19. I agreePhoto ReleaseOccasionally, Canyon Arts & Creeks Camp will photograph campers during our summer sessions. Photos may appear on our website at www.canyonartscamp.com. Photos are used for the purpose of illustrating and promoting the camp experience and our programs. We need your signature on file if you give permission to use photos of your child for promotional purposes.*Occasionally, Canyon Arts & Creeks Camp will photograph campers during our summer sessions. Photos may appear on our website at www.canyonartscamp.com. Photos are used for the purpose of illustrating and promoting the camp experience and our programs. We need your signature on file if you give permission to use photos of your child for promotional purposes. I give permission to Canyon Camp to use photographs of my child(ren) while attending summer camp I do not give permissionAre you a spammer? Of course you're not!Δ
