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I understand that it is my responsibility to apply and/or provide my camper with both sunscreen and/or bug repellant if I desire them to have it. The Prairie Springs staff will not supply or administer sunscreen or bug repellant for any camper.

Camper's Full Name:
Camper's Age:
Camper's Birthdate:
Phone:	( ) - Second three digits Last four digits
Home Address:
City:
State:
ZIP code:
Grade camper is going into:
Camper's School:
Camper's T-shirt Size:	Emergency Contact Information
1st Contact Name:	Please list yourself first.
Relationship:
Phone:	( ) - Second three digits Last four digits
Secondary Phone:	( ) - Second three digits Last four digits
Email:
2nd Contact Name:
Relationship:
Phone:	( ) - Second three digits Last four digits
Secondary Phone:	( ) - Second three digits Last four digits
3rd Contact Name:
Relationship:
Phone:	( ) - Second three digits Last four digits
Secondary Phone:	( ) - Second three digits Last four digits
Insurance:	Please list the primary insurance holder for this camper
Check to Confirm:	I give my permission for all emergency contacts to have permission for pick-up. Camper Release Our camper check-in / check-out policy will only allow us to release your camper to guardian designated individuals. We may require ID to verify identification. We will not release campers to individuals not indicated. Please use the space below to list additional individuals with permission to pick-up your camper.
Name and Relationship:
Name and Relationship:
Name and Relationship:	Sunscreen and Bug Repellant
Sunscreen:	My camper is allowed to self-apply sunscreen Yes No
Bug Repellant:	My camper is allowed to self-apply bug repellant Yes No
Check to Confirm:	I understand that it is my responsibility to apply and/or provide my camper with both sunscreen and/or bug repellant if I desire them to have it. The Prairie Springs staff will not supply or administer sunscreen or bug repellant for any camper. Medical Information Does your camper have:
Food allergies (peanuts, dairy, etc.)?:	Yes No
If yes, please list:
Allergies to medications (Benadryl, latex, etc.)?:	Yes No
If yes, please list:
Environmental allergies (bugs, plants, etc.)?:	Yes No
If yes, please list:
An Epi Pen they carry?:	Yes No
If yes, please explain why:
Any physical restrictions our staff should be aware of?:	Yes No
If yes, please list:
Any medical conditions (asthma, etc.) our staff should be aware of?:	Yes No
If yes, please list:
Any medications that they will be responsible for during camp?:	Yes No
If yes, please list:
Additional Information?:	Is there any additional information about your camper we should be aware of? If yes, please list.
Is your child up-to-date on current vaccinations?:	Yes No
Check to Confirm:	I give my permission to Prairie Springs staff to administer first aid to my child, or to seek medical treatment for my child, if the need arises. Consent
Confirm Consent:	I certify that all of the information I listed above is true and correct to the best of my knowledge. My signature below indicates that I understand there are no refunds for cancellations within two weeks (14 days) of a camp’s start date. My signature below grants permission for the Carroll University’s Prairie Springs Environmental Education Center staff to transport my child for off-site field trips if needed (full-day camp only). I understand that some day camp programs will include wading into the pond or stream with supervision, and I give permission for my child to do so. I give my permission to Carroll University to administer first aid to my child, or to seek medical treatment for my child, if the need arises. Yes No

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