Welty 2021-22 No School Day Emergency Contact Information
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Camper's Name *
Parent’s/Guardian’s Name 1 *
Parent’s/Guardian’s Address 1 *
Parent’s/Guardian’s Phone(s) 1 *
Parent’s/Guardian’s Name 2
Parent’s/Guardian’s Address 2
Parent’s/Guardian’s Phone(s) 2
Emergency Contact 1 (Name and Phone Number) *
Emergency Contact 2 (Name and Phone Number) *
Hospital/Clinic Preference *
Physician’s Name And Address *
Physician’s Phone Number *
Insurance Company *
Insurance Policy Number *
Allergies/Special Health Considerations: Please list any special health-related needs of child (allergies, medications, injuries, emotional or physical conditions)
Any conditions that limit mental or physical ability that we should be aware of?
Any other special needs your child may have?
I understand that my camper will be required to wear a mask while at camp, except during lunch or snacks. During lunch and snack, campers will be separated, have their own table if inside, two to a table if outside.   *
I understand that my camper will be asked health questions and have their temperature taken every day upon drop off.  If a camper has symptoms or a temperature of 100.4 F, they will not be allowed to stay at camp. *
I understand that if my child exhibits symptoms or a temperature of 100.4 F, they will not be allowed to stay at camp. They will be separated from other campers and a call will be made to have the camper picked up within 30-minutes of the call. The camper will not be allowed to return to camp for 72-hours and must not exhibit symptoms or a fever. A refund will not be processed. *
I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency. I agree to pay all costs and fees contingent on any emergency care and/or treatment for my child as secured or authorized under this consent. *
I understand that if my child exhibits disruptive behavior during a camp session, especially if it creates an unsafe environment for the child or other campers, Welty will call to have that child picked up and removed from camp.  Welty will evaluate the severity of the incident with the child’s parents to determine if they can return to camp the following day. *
I give permission for my child to be photographed and recorded. Pictures and video will be used by Welty on social media plat forms. *
I give permission for my child to participate in hiking and other activities at Big Hill Park for Welty learning programs. I release Welty Environmental Center and individuals from liability in case of accident during activities related to Welty programs, as long as normal safety procedures have been taken. *
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