Ingham County Parks
Exploring Nature Day Camp
THIS FORM MUST BE SUBMITTED AT LEAST 5 DAYS PRIOR TO SESSION START DATE
Camp Session Number:
Session Date From:
To:
Camper Name:
Sex:
Female
Male
Age:
Birthdate:
Grade just completed in school:
Does Camper have any communicable diseases?
No
Yes
If you answered yes please explain:
Does Camper have any allergies (food, medications, etc.)?
No
Yes
Please list any allergies/medications. Include name, dosage, frequency and dispensing method for any medication.
Is Camper allergic to bee stings?
No
Yes
(If yes, please provide antivenin in a cooled container.)
Date of Campers last tetanus shot: (Please get this date from your Doctor):
Are Campers immunization shots current?
No
Yes
Can Camper swim?
No
Yes
Can Camper stay afloat?
No
Yes
Please note anything special we should know to ensure your Campers comfort and enjoyment while at day camp.
Parent/Guardian Contact Information
Name:
Address:
Home Phone:
Work Phone:
Cell Phone:
E-Mail Address
If parent(s)/guardian(s) cannot be reached, the alternate contact is:
Name:
Address:
Relationship:
Phone:
Family Physician Information
Physician Name:
Phone:
Emergency Hospital Care
Emergency Care Hospital preferred (Ingham Medical Center is the closest):
By submitting this form I give my permission for the Camp Naturalist to dispense medication if brought into camp and permission for a doctor to administer routine first aid and emergency medical treatment if staff is unable to contact parent/guardian.
(Signature required on first day of camp.)
Parent/Guardian Signature:
Date:
Questions for Parent/Guardian
Would you say your child acts:
1
2
3
4
5
Old for his/her age . . . . . . . . . . . . . . Young for his/her age
Would you say your child is:
1
2
3
4
5
Solitary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social
Would you say your child is:
1
2
3
4
5
Quiet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Active
Questions for Camper
What is your favorite subject in school?
Why?
What subject is most difficult for you in school?
Why?
I would rather work:
Alone
In Groups
I do my best work:
Alone
In Groups
What kind of books do you like to read (some examples: mysteries, history, fairy tales...)?
What kind of games do you enjoy playing (soccer, checkers, marbles...)?
If you couldn't watch TV or play video games at home, what would you do?
If you could learn about anything, what would it be?
Parents or Camper, Please feel free to provide any additional comments here: