Registration Forms for Licensed Camps

Uses these online forms to submit all the info for your child’s registration for our Licensed Camps such as Champ Camp, PAL Camp and school break programs.

Authorization to Give Medication

Child's Name*
First Last
Program the Child is Participating In
Name of Medication*
Reason Medication is needed during program hours*
Dose and Delivery/Route Details*
Time of administration of the medicine*
Does the medicine need to be refrigerated
- Yes
- No
Additional instructions
Date to begin medication
Date Format: MM slash DD slash YYYY
Date to stop medication
Date Format: MM slash DD slash YYYY
Known side effects of medicine
Plan of management of side effects
Child allergies
Prescriber’s Information
Prescribing Health Professionals Name
Doctors Phone Number
Name of Pharmacy
Pharmacy phone number
Permission to Give Medicine
I hereby give permission for the camp program to administer medicine as prescribed above: I also give permission for the caregiver/teacher to contact the prescribing health professional about the administration of this medicine. I have administered at least one dose of medicine to my child without adverse effects.

* Please note that medication cannot be administered until the above information is filled out
Parent or Guardian Name
First Last
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Licensed Day Camp Registration

GENERAL INFO

BACKGROUND INFORMATION

EMERGENCY CONTACT INFORMATION

MEDICAL EMERGENCY INFORMATION

PICK UP INFORMATION

PERMISSION FORM

Form Submission

Authorization to Give Medication

Prescriber’s Information

Permission to Give Medicine