Welty 2022 Summer Camp 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 Welty strongly recommends that all campers be vaccinated against COVID-19 to ensure the highest safety possible for all campers and staff and to also reduce the possibility of camp closures due to close contact. CDC recommendation for close contact for un-vaccinated individuals is to quarantine for 10 days. Those that are vaccinated (including any recommend boosters) and are not showing symptoms many continue to attended camp. Refunds for missed days will not be issued.      *
Masking. We will following the County Level guide as provided on the CDC website (https://www.cdc.gov/coronavirus/2019-ncov/your-health/covid-by-county.html). If Rock County is "low" or "Medium" masking will not be needed, but any would be free to wear one at anytime. If "high," we will mask indoors, except during lunch or snacks. *
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. *
If your camper is showing symptoms, they should be kept at home. At any time a camper shows symptoms, the camper will be separated from the others and sent home. Campers will be allowed to return after 72 hours of controlled temperature without medication. A refund for missed days will not be issued. Campers that take an at-home test and test negative and do not have a fever, may return to camp sooner. Refunds for missed days 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 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. *
I understand that my child will participate in field trips that include riding on a bus.   *
I give permission for my child to be photographed and recorded. Pictures and video will be used by Welty on social media plat forms. *
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