Camper's Name *

First Name

Last Name

Gender *

Male

Female

Birth Date *

MM

DD

YYYY

Camp Session *

Choose the session for the grade your child will be going into.

3rd and 4th Grade

5th and 6th Grade

Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent's Name *

First Name

Last Name

Phone *

(###)

###

####

Family Doctor - Phone *

(###)

###

####

Does the camper have any dietary restrictions, food allergies, or medical allergies? *

In case of restricted diet, parents may need to provide some food items. Please call the camp for more information.

Yes

No

May we give your child Tylenol for pain relief? *

Yes

No

Is the camper taking medication (including Ritalin), which must be continued during camp? *

Yes

No

Should the camp staff should assist in giving the medication to your child? *

Yes, I would like staff to help assist my child with their medication. I have attached their schedule above (if applicable).

No, my child will be responsible for their own medication while at camp and I will not hold Camp Woody staff responsible.

Photo Release (optional)

I give Camp Woody permission to use my child's photo in future brochures, CD presentations and/or posters to be used for promoting and advertising the camps programs

I Agree

Medical Authorization *

In the event that I cannot be reached in an emergency, I give permission to the staff or board member of Camp Woody to give consent to a physician, EMT, and/or hospital to give emergency medical treatment.

I Agree

Health Statement *

The camper is in good health and is able to attend Camp Woody.

I Agree

Participation Statement *

The camper is able to participate in all camp activities, unless noted otherwise.

I Agree

Signature *

By typing your name below, you agree to the above medical authorization, health statement, participation statement, and the accuracy of the provided information.

First Name

Last Name