Camper Registration Form | Jensen Woods Camp

Summer Camp Registration Form

This form is required for all camp attendees.

Although not required, logging into your account first will help us pre-fill some of the form information for you.

If you need to finish at another time, you can use the “save & continue later” feature to email yourself a link to your partially completed form.

All in One Authorization Form

Each Registrant must complete this form in order to participate.

"*" indicates required fields

Step 1 of 4

25%

Section I: Camp

Camp Name*

Section II: Personal Information

Participant Name*

Date of Birth*

MM slash DD slash YYYY

Age

Address*

Street Address Address Line 2 City State ZIP Code

Participant Phone

Custodial Parent Information

Parent Name*

First Last

Address

Same as participant address above

Street Address Address Line 2 City State ZIP Code

Email*

Cell Phone

Alternate Phone

Emergency Contacts

Edit or add as needed.

Primary Emergency Contact

Em Contact Phone

Alternate Emergency Contact

Alt Em Contact Ph

Section III: Medical Insurance

Medical Insurance*

Is the camper covered by a medical insurance policy?

Yes

Name of policy holder

Relationship

Insurance Company

Policy #

Policy Type

Group Plan

Individual Family Plan

Insurance Co Phone

Section IV: Medical History

Imunizations*

Is camper current on all immunizations as required by the public school system?

Yes

Date of last Tetanus shot

MM slash DD slash YYYY

Common Allergies*

None

Peanuts - airborne (must remove anything containing peanuts)

Peanuts - Can't be ingested

Lactose - No milk or dairy products in food at all

Lactose - Milk can be in food

Other Allergies

Medications

Current Medical Issues

Medical Restrictions

Prohibited Medications

Doctor's Name

Doctor's Phone

Medical Authorizations

Please check the following permissions and affirmations to signify agreement

Medical Treatment Authorization

I authorize camp staff to obtain and consent to medical treatment for my child in case of injury or illness during camp

Transportation Authorization

I authorize Jensen Camp Foundation and its designees to transport my child to off-site activities and/or for health or safety

OTC Medicine Authorization

I authorized camp staff to administer the following OTC medicines in appropriate dosage under appropriate circumstances.

Acetaminophen (temp/pain reliever)

Diphenhydramine (Benadryl/allergy)

Suphedrine (Sudafed/allergy)

Loperamide (Antidiarrheal)

Ibuprofen (temp/pain reliever)

Guaifenesin (Robitussin/Cough Syrup)

Section V: Add'l Camper Release Authorizations

All campers are to be released only to an authorized person.
Parents/guardians must complete and sign a form (see below) authorizing release of the camper to anyone other than the custodial parent or legal guardian.
Identification may be required for release of campers to authorized persons. Authorized persons are to be directed to the camp counselor, dean, or camp director to sign their camper out.
If a custodial parent requests that a camper not be signed out to a noncustodial parent, such a request must be in writing to be kept on file.
When a last-minute change occurs in who will be picking up a camper, the new instructions are to be verified with the camp director from an authorized person.

I hereby authorize the following persons to pick up my child or children at the end of the session:

Name

Relationship

Name

Relationship

Name

Relationship

Liability Release and Agreement

For Parents/Guardians of Youth Participants:

I, the undersigned parent or guardian, do hereby grant permission for to attend Camp. As the parent/guardian, I understand that I am responsible to transport the youth home if he/she is found in violation of the rules.

For Parents/Guardians and All Participants:

Further, I understand that participation in Jensen Camp Foundation activities can involve a certain degree of risk and can from time to time be physically, mentally and emotionally demanding.

I have educated myself as to the nature of the activities that I (my child) will be participating in, have been provided an opportunity to have questions about said activities answered, and have considered the risks involved in participating in said activities.

I do hereby voluntarily give my consent (for my child) to participate in each of these activities. I understand that participation in any Jensen Camp Foundation activity is completely voluntary and that I (my child) can refuse to participate in any activity I (he, she) deem(s) to be inappropriate for me (him, her).

I release the Jensen Camp Foundation, its activity coordinators and all employees, volunteers and agents of the Jensen Camp Foundation (the “Released Parties”) from any and all claims of liability arising out of my (my child’s) participation in any Jensen Camp Foundation camping and youth activities, including any claim arising out of travel to or from the site of the location of these activities.

I further agree that if I or if anyone on behalf of my child makes a claim for damages against any of the Released Parties, that I will indemnify and hold harmless each of the Released Parties from any and all such liability, damages, attorneys’ fees and costs that any of the Released Parties may incur as a result of said claim or claims, to full extent allowed by applicable law.

Liability Release*

I agree to the above stated liability Release.

Media Release

I understand that interviews, photographs, or video footage of my child or myself may be used by Jensen Camp Foundation for promotional purposes.

Equine Act*

I am aware that my child will be near to or riding horses, which are large animals, can be unpredictable, and can bite, buck and kick. I am aware that participants must be alert when near them and follow all guidelines and procedures concerning their care and handling. As per the Illinois Equine act.

e-Signature Section

My signature below verifies enrollment of the camper named in Section II at the Jensen Camp Foundation/Jensen Woods Camp activity, subject to the conditions and permissions set forth in this form.

e-Signature*

Type your full name below to sign this agreement.

e-Signature Date

MM slash DD slash YYYY

19947