Youth Program Form (FOR SUMMER CAMP)

Child's First and Last Name

Please use the child's legal first and last name.

Child's Pronouns

Pronouns are the terms your child feels comfortable being referred to by in conversation. For example, She/Her. He/Him, They/Them.

Child's Age

Birth Month

Birth Date

Please list any allergies the child has.

What happens when the child is exposed to the allergen?

Does your child carry an inhaler?

What allergy is the Epi-Pen for?

Does your child have asthma?

Does the child have any immunization exemptions because of a parental/guardian objection or medical reasons?

If yes, please describe any injuries, conditions, or physical limitations.

If yes, please list which immunizations your child has not received/is exempt from.

ADD/ADHD

Autism/Aspergers

Sensory Sensitivity or Sensory Processing Disorder

Dietary Restrictions (Vegetarian, Gluten Free, Allergies, Kosher, etc)

Frequent Upset Stomach

Frequent Headaches

Diabetes

Fainting or Dizziness

Hearing Condition

Vision Condition

Heart Condition

Mental or Developmental Disorder

Daytime Wetting

Bleeding or Clotting Disorder

Other

Please describe any of the checked boxes above.

Please list the legal name(s) at least one parent/guardian, as well as each parent's cell phone number.

Please provide legal names and phone numbers of 1-2 NON-PARENT Emergency Contacts.

What should our youth programs staff know about your child?

Click to Sign

Parent/Guardian Signature

NOTE: Terrapin Adventures does not accept paper waivers, please submit electronically.