EDUCATION — Camp cbg

emergency medical information and authorizations

Child's name:

Last name:

First name:

Birth date:

Person who registered child:

Email registration confirmation to:

My child is enrolled in (please check appropriate box):

My First Camp (Age 2)   My First Camp (Age 3)   Green Sprouts(Ages 4-5)  
Green Thumbs (Ages 6-7)   Explorers (Ages 8-9)   Adventurers (10-12)   LIT (13-15)
Break Camp

By registering for Camp CBG, I consent that my child/ren may be photographed,
and to the use of such photographs in future Chicago Botanic Garden publications and promotional materials.

Medical History and Emergency Authorizations

I attest that my child is in good physical and mental health. Any special considerations are indicated below. In case of accident or illness, I hereby give permission that my child may be given emergency treatment and, further, I authorize and consent to the administration of any and all medical, dental, and surgical examinations or operations and treatment or all other related care, including the administration of drugs, tests, anesthesia, and/or blood transfusions to the above named child that may be ordered by the medical care provider in attendance at the facility deemed necessary for medical treatment. I hereby consent to the release of medical report(s) to any medical care provider and consent to the admission of the above-named child to a hospital. I agree to be responsible for any medical expenses incurred on behalf of my child.

Person to Contact in an Emergency:

Alternate Emergency Contact:

Doctor's Name:

Doctor's Phone:

Medical Insurance Company:

Medical Insurance ID Number:

Date of child's most recent physical examination:

1. Allergies: Yes   No
    Please list allergies below. If your child has a peanut or tree nut allergy,
    please be specific as to the severity.

2. My child may have sunscreen applied during the day: Yes   No

3. My child may partake of the peanut-free camp snack with no restrictions.
(If NO, please provide daily snack for your child.) Yes   No

4. Does your child routinely require Medication? Yes   No
    Please list medical concerns (including medications, past health problems, etc.):

5. Limitations on activities:

6. Behaviors of which staff should be aware:

    How do you handle this behavior:

7. Other:

carpool/pick-up authorizations

I hereby authorize the following individuals to pick up my child
(Please do not list names listed above):

NOTE: Written notification my parents or guardian MUST be given for pick-up by someone other than persons listed. Please let us know in advance if there are any issues regarding pick-up/drop-off of which we should be aware (custody disputes, etc.)

CAMPER CODE OF CONDUCT

• Campers will treat their fellow campers, instructors, and volunteers with respect.
• Campers will follow directions and stay with their group.

Please read and discuss these expectations with your child. In the event that a camper does not follow the Code of Conduct, or his or her behavior endangers other campers or interferes with an instructor's ability to provide programming, the instructor will inform the parent and the Coordinator of Youth Services at pick-up or through a phone call. If a second incident occurs, parents may be asked to accompany their child during camp, or withdraw from camp. Refunds will not be given for behavior-related withdrawals.

I have read and discussed this Code of Conduct with my child. (Please check box.)

I understand that by completing and submitting this Medical Form via electronic transmission that I acknowledge the above statements and my submission of this form on-line shall substitute for and have the same legal effect as an original form signature.