Welcome to The Center, Palos Park

Camper Information - Step 1 of 4

Camper Name *

First

Last

Camp Program - Please choose carefully! *

Overnight Campers stay on site from Sunday - Friday. Daytime Only campers will be picked up at 9pm daily and sleep at their own homes.

Original Order Number (can be found in email) *

Birth Date *

Age at Camp *

Sex Assigned at Birth *

Male
Female

Gender

Legal Parent/Guardian #1 *

First

Last

Relationship to Camper *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Home or Work Phone

Legal Parent/Guardian #2 *

First

Last

Relationship to Camper *

Address (if different than above)

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Home or Work Phone

Emergency Contact #1 *

First

Last

Relationship to Camper *

Best Phone Number for Emergency Contact *

Emergency Contact #2 *

First

Last

Relationship to Camper *

Best Phone Number for Emergency Contact *

Is the camper covered by family medical/hospital insurance? *

If yes, indicate medical/hospital carrier:

Policy Number

Name of Insured

Relationship to camper:

Please upload a photo of insurance card:

Click or drag a file to this area to upload.

Your family's medical insurance is expected to provide primary coverage for illness and accidents, with The Center's insurance providing additional accident coverage (such as your deductible amount and expenses beyond the scope of your coverage). The Camp will make every effort to contact you in the event that your child needs medical attention, so that you may choose to take your child to your own doctor or treatment facility. If your child's condition necessitates our obtaining medical treatment for them, we will do so, as we continue our efforts to contact you.

Emergency Authorization

In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, order appropriate diagnostic testing, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for the camper named above.

Signature of parent or legal guardian *

Name:

Parents will be notified of illness or injury to campers in the following cases: temperatures over 100.3 degrees, injury or illness needing the care of a physician, any other unusual illness, injury or behavior that the camp director believes the parent would want to know or for which the parent has specifically requested notification.

This health history is correct so far as I know and the above named camper has my permission to engage in all activities except as noted. I hereby give my permission to The Center to 1) provide ongoing health care including MOTRIN, TYLENOL, ANTIBIOTIC OINTMENT, HYDROCORTISONE, ORAL & CREAM BENADRYL, INSECT REPELLENTS CONTAINING DEET and other medications as prescribed and 2) To select medical personnel and to arrange or provide necessary related transportation.

Signature of parent or legal guardian *

Comment

COVID19

Emergency Authorization

Camper Code of Conduct - Please print or 'save as' to read in entirety

Parental Release & Camper Waiver - Please print or 'save as' to read in entirety

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COVID19

Emergency Authorization

Camper Code of Conduct - Please print or 'save as' to read in entirety

Parental Release & Camper Waiver - Please print or 'save as' to read in entirety

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