Camper Information Form

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1 Camper Information Form One form per participant Print clearly and legibly Completed form required for participation Must be completed by parent or legal guardian Must be received one week prior camp CAMPER INFORMATION Camp, YEAR Location Camper s Name: Birth : Age at time of camp: o Male o Female Address: City: State: ZIP: Gwinnett Resident: o Yes o No Names of Siblings in GCPR camps: Known Allergies (include food, medication, latex, etc.): Recent Illnesses or Injuries (last 6 months): Recent Prescription Medications (last 6 months): List all special circumstances, emotional or physical conditions regarding your child. Failure to disclose information or conditions may result in child being disallowed registration or removed from participation. If removed due to failure to disclose, no refund or transfer of fees is allowed. If accommodation requests are made less than two weeks in advance, Gwinnett County Parks & Recreation will make every effort to meet the request. If we are unable to meet the request in time, GCPR reserves the right to limit or disallow registration for the requested session. However, the participant will be eligible to register for another program later in the session. Parent/Guardian #1 (same address with camper) PARENT/GUARDIAN INFORMATION Name: Address: Home Phone: Cell Phone: Work Phone: Parent/Guardian #2 Name: Address: Home Phone: Cell Phone: Work Phone: Address (if different): City: _ State: ZIP: PICK-UP/DROP-OFF/EMERGENCY CONTACT (if above do not respond) You authorize this list of people to act as a caregiver and pick-up/drop-off your child and if needed be contacted in an emergency situation. Parents/Guardians will remain the first point of contact in an emergency. Photo I.D. must be provided upon sign-out. Name Relationship to Participant Contact Number LIABILITY RELEASE, INDEMNIFICATION AND MEDICAL AUTHORIZATION I am aware of the nature of this activity and I hereby assume responsibility for my child (name of child), to participate in the Camp Program. I understand that such participation may include being photographed for publicity purposes and riding in Gwinnett County vehicles to activities which are not located on Gwinnett County property. I understand that participation in the Summer Camp Program can result in bodily injuries to my child, including but not limited to, contusions, cuts, scrapes, head and/or dental injuries and broken and/or sprained limbs. I will not hold Gwinnett County and/or its elected and appointed officials, officers, employees, agents and volunteers responsible in the case of accident or injury as a result of child s participation in the Camp Program. I further agree to indemnify, defend and hold harmless Gwinnett County, its elected officials, officers, employees, agents, and volunteers from any and all claims arising from participation in the Summer Camp Program and its related activities. Such indemnification shall include, but not be limited to, liability settlements, damage awards, costs and attorney s fees associated with any such claim. In situations which are true emergencies and only when I cannot be reached immediately, I authorize a representative of Gwinnett County, Georgia to obtain immediate medical care and I consent to the hospitalization of, the performance of necessary diagnostic tests upon, the use of surgery on, and/or the administration of drugs to my child if an emergency occurs when I cannot be located immediately. I will not hold Gwinnett County and/or its elected and appointed officials, officials, employees, agents and volunteers responsible for injuries or damages sustained by my child as a result of the immediate medical care. I understand that I am responsible for payment of medical expenses. Name of Insurance Company: Policy Number: Child s Physician/Clinic: Phone Number: Signature of Parent/Guardian: : Camp must have minimum enrollment in order to operate

2 Waiver of Liability (Patron to ride in County vehicle) Name Address Phone of Birth / / Emergency Contact Name/Phone ; ( ) Not being employed by any branch of Gwinnett County Government, I do hereby request permission to accompany a Gwinnett County employee in a Gwinnett County vehicle. I understand that, as a condition of accompanying an employee of the Gwinnett County Board of Commissioners, I relieve and absolve the Gwinnett County Board of Commissioners and its employees of any and all claims, lawsuits, or any causes of action that may arise from accompanying said employee. I further release, renounce and waive all claims, lawsuits or any causes of action against the insurance company which insures the Gwinnett County Board of Commissioners and its vehicles. Signature Witness Signature

3 Behavior Management Policy Read, sign and bring with Camper on first day of any camp attended. Thank you! In order to maintain a friendly, fun and safe environment in our camp programs, we have adopted the following policies regarding behavior management of campers. These policies ensure that each camper will achieve the fullest possible positive experience from their camp. 1. Campers Bill of Rights: Campers will exhibit proper manners; Campers will show respect and consideration for fellow campers; Campers will respect the authority of Camp Staff; Campers will respect camp supplies, equipment and facilities; Campers will communicate their needs or concerns to Camp Staff; Campers will respect other campers belongings; Campers will listen and follow instructions from Camp Staff and willingly participate in all activities. 2. List of Unacceptable Behaviors: Campers are not permitted to use violence, force or intimidation; Campers may not use name calling or inappropriate language; Campers may not destroy or deface camp supplies or property. 3. Consequences in Behavior Management Policy: Camp Staff will praise and reward campers who exhibit exemplary behavior. Our staff is also trained to recognize, act swiftly and use the following steps to correct a camper s misbehavior: Behavior/Action Level 1 Corrective Action Bullying, name calling, swearing, unsportsmanlike conduct, not following staff directives Level 2 Reported to Camp Director Report to parent/guardian Apology 5 minute time out Complete a Report of Inappropriate Behavior Form Kicking, biting, violence, stealing Level 3 Reported to Camp Director Call parent/guardian Parent conference Possible suspension Possible dismissal Complete a Report of Inappropriate Behavior Form Hitting, fighting, leaving campsite unsupervised, inappropriate touch, any illegal activity Reported to Camp Director Call parent/guardian Parent conference Suspension/ Dismissal Complete a Report of Inappropriate Behavior Form Summer Camp Participant I,, (Camper s Name) have read (or have had read to me) the Behavior Management Policy (above, and also in the Parent Handbook), and know that I am expected to follow this policy while I am a summer camp participant with Gwinnett County Parks & Recreation. My parents/guardian also took the time to make sure that I understood any part of the policies. If I did not understand any part of the policies, my parents/guardians explained them to me. Camper s Signature Parent/Guardian I,, (Parent/Guardian) confirm that I have reviewed and discussed the Behavior Management Policy (above, and also in the Parent Handbook) with my child. I acknowledge that following my review of this policy and the Parent Handbook, that any questions or concerns I may have had have been answered by Gwinnett County Parks & Recreation staff. As a parent/guardian of a summer camp participant, I agree to adhere to and enforce the policies and procedures set forth here, and in the Parent Handbook. Parent/Guardian Signature

4 GWINNETT COUNTY PARKS & RECREATION SUMMER CAMP PROGRAM Prescription/Nonprescription Medication Information Form *Please Print**Form must be completed by parent, legal guardian or caregiver. 1. Name of Person who will be taking medication: a. Age of person taking medication: b. Does person taking medication administer medication to himself/herself? Yes or No 2. Name of Medication(s) to be taken: (NOTE: must match prescription container.) a. b. 3. Directions for taking medication per the prescribing doctor: (NOTE: must match prescription container) a. b. 4. Adverse/Negative reaction(s) if Medication is NOT taken as prescribed: a. b. 5. Doctor prescribing medication: Doctor s phone number in case of emergency:_ 6. Name of parent, guardian, or caregiver In case of emergency: Name: Phone (Home) Phone (Work): Name: Phone (Work): Phone (Cell): Phone (Home): Phone (Cell): Medication Waiver/Release I,, (mother, father, legal guardian, caregiver) of the above named participant verify that all the above information to be true, assume all risks and hazards incidental to my child s participation in the Summer Day Camp program sponsored by Gwinnett County. I hereby, for myself, my heirs, executors and administers waive and release any and all rights and claims for damages against Gwinnett County and it s representatives, successors and assigns for any and all injuries suffered by the above named participant during the Summer Camp program. Signature

5 GWINNETT COUNTY PARKS & RECREATION SUMMER CAMP PROGRAM Medication Dispensing Log *Please Print**This form must be completed by parent, legal guardian or caregiver. Camper Name: DAY Medication name #1 Time Due Medication Name #2 Time Due MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY Signature of Parent, legal guardian, caregiver Printed Name ** This portion of form must be completed by Camp Director/Assistant Director. DAY Medication name #1 Time Due Medication Name #2 Time Due MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY Signature of Camp Director Comments:

6 GWINNETT COUNTY PARKS & RECREATION SUMMER CAMP PROGRAM EpiPen Permission Slip I,, hereby grant to Gwinnett County Parks & Recreation staff, summer camp staff, and summer contracted staff, discretionary authority to administer to (my child) the EpiPen that I have supplied to the camp staff. I furthermore agree to indemnify, defend and hold harmless Gwinnett County, its elected officials, officers, employees, agents, and volunteers, from and against any and all claims, demands or lawsuits arising from the administering of the EpiPen. Such indemnification shall include, but shall not be limited to, liability settlements, damage awards, judgments, costs and attorneys fees associated with any such claim. I will not hold Gwinnett County, its elected and appointed officials, officials, employees, agents or volunteers responsible for injuries or damages sustained by myself or my child as a result of administering the EpiPen. Signature of Parent/Guardian

7 Gwinnett County Parks and Recreation Summer Camps ADVENTURE CAMP 2017 PAYMENT SCHEDULE WEEK # WEEKLY THEME AND DATES PAYMENT DUE Check Off When Paid 1 Summerfest June 5 - June 9 Monday, May 22, To the Sky and Beyond June 12 - June 16 Tuesday, May 29, On Your Mark June 19 -June 23 Monday, June 05, Sail Away June 26 - June 30 Monday, June 12, 2017 No Camp Week of July 4th 5 Splashtacular July 10 - July 14 Monday, June 26, Holidaze July 17 - July 21 Monday, July 03, Old School Summer July 24 - July 28 Monday, July 10, 2017 Camp Refund Policy Written withdrawal requests received more than fourteen (14) days prior to the start of camp will receive a refund, minus the Camp Payment Plan Fee ($50) and Transaction Fee ($1). No refunds will be issued for requests made less than fourteen (14) days prior to the start of camp. Camp Payment Plan Fee and Transaction Fee is non-refundable and non-transferable and cannot be issued as a credit toward any class, program, or event. Campers will need to wear comfortable loose fitting clothes and tennis shoes. They also need to bring a swim suit (with lining) and towel to go swimming. Bring two snacks, a lunch (no peanut products), and a refillable water bottle each day. Your child's camp registration is not complete until a summer camp registration packet has been completed in its entirety and received at the camp location. The summer camp registration form and parent handbook are available for download at

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