Camper Application

Camper Information

First Name (required)

Middle Name (required)

Last Name (required)

Date of Birth (required)

Gender (required)

Family Information

Personal Information

Family Role (ex: Mother, Legal Guardian, etc.) (required)

First Name (required)

Middle Name (required)

Last Name (required)

Email (required)

Profession (required)

Primary Address

Home Type (ex: House, apartment, etc.) (required)

Street Address (required)

City (required)

State (required)

Zipcode (required)

Phone Number (required)

Spouse Personal Information (optional)

Family Role (ex: Mother, Legal Guardian, etc.)

First Name

Middle Name

Last Name

Email

Profession

Spouse Primary Address

Street Address

City

State

Zipcode

Phone Number

Medical History - Medication & Allergies

No Known Medication Allergies

Otherwise, please indicate any known medication allergies below: (all required)

YesNoAMOXICILLIN
YesNoBACTRIM/SEPTRA/SULFA
YesNoIBUPROFEN
YesNoPENICILLIN
YesNoTYLENOL
YesNoOTHER MEDICATIONS

If you indicated other medications, please list them:

Medical History - Allergy History

No Known Allergies

Otherwise, please indicate any known allergies below: (all required)

YesNoINSECT STINGS
If yes, list insects:

YesNoPOISON IVY, POISON OAK, OR SUMAC
YesNoPEANUTS
YesNoEGGS
YesNoCOW’S MILK
YesNoGLUTEN
YesNoSHELLFISH
YesNoOTHER FOOD ALLERGIES

If yes, list foods:

Medical History - Health History

No Known Health Conditions

Otherwise, please indicate any known allergies below: (all required)

YesNoASTHMA
YesNoADD / ADHD
YesNoHYPOGLYCEMIA
YesNoMIGRAINES
YesNoSEIZURE DISORDER
YesNoHARD OF HEARING/DEAF
YesNoCARDIAC ISSUES / HYPERTENSION
YesNoBLADDER / KIDNEY
YesNoSLEEP WALKING
YesNoNIGHT TERRORS
YesNoCELIAC DISEASE
YesNoECZEMA
YesNoDIABETES
YesNoSICKLE CELL ANEMIA
YesNoCAMPER BECOMES ILL WHEN EXERCISING IN THE HEAT
YesNoPHYSICAL DISABILITY (MUSCULAR/COORDINATION)

If yes, list physical challenges:

YesNoHAS CAMPER BEEN HOSPITALIZED IN THE LAST YEAR?

If yes, please provide details:

YesNoANY ACTIVITIES CAMPER IS RESTRICTED FROM DOING?

If yes, list restrictions:

YesNoOTHER CONCERNS/DISORDERS

If yes, list other concerns:

Medical History - Social Concerns

No Known Social Concerns

Otherwise, please indicate any known social concerns below: (all required)

YesNoDEPRESSION

If yes, provide details:

YesNoANXIETY

If yes, provide details:

YesNoBI-POLAR / PSYCHO - SOCIAL DISORDER

If yes, provide details:

Medical History - Emergency Contacts

Medical History - Medications

No Medications Needed

Medicine will not be dispensed unless the following guidelines are met:

• If you are bringing prescription medications, they MUST be in the original pharmacy labeled container or the original manufacturer’s container.

• Prescription medications MUST have your attendee’s name on the bottle.

• Any doctor’s office samples MUST be accompanied by a signed physician prescription.

• Please limit the amount of medication to only what is required for your attendee’s term.

• Our camp provides most common over the counter medications. Please do not send these items. If your attendee does not have any medications, then you can skip this step and move on to the Next step.

Medical History - Insurance

Name of Insurance Company:

Policy Number:

Insurance Company phone number:

Your doctor's name:

Your doctor's phone number:

Miscellaneous Information

(required)

Camper's Ethnic Background
African AmericanLatinoCaucasianOther

Are Both Parents Living?
YesNo

Who does the camper live with?
Both ParentsMotherFatherGrandparent(s)Other

Camper T-Shirt Size:
YSYMYLYXLASAMALAXL

Cell phones are not allowed for campers during camp. If discovered, they will be confiscated and returned when camp is over. Can your camper abide by this policy?
YesNo

Release and Signature of Agreement

Medical and Liability and Image Release
Please read the following waiver and release. Below it, you can enter you name if you agree with the terms, and if you verify that all information given is true to the best of your knowledge

Waiver and Release.  Camper covenants not to sue and does hereby release, forever discharge, and agree to hold harmless and fully indemnify Camp Amplify Inc. and its affiliates, officers, directors, staff, employees, agents, volunteers, counselors, sponsors, heirs, administrators, successors and assigns (the “Released Parties”), from any and all liability, claims, demands, damages, expenses, and causes of action of whatever kind or nature, either in law or in equity arising out of or relating to (i) Camper’s participation in Camp Amplify Inc. and (ii) first aid or medical treatment provided to Camper in connection with his or her participation in Camp Amplify Inc. Without limiting the generality of the foregoing, Camper understands and acknowledges that the foregoing covenant not to sue, release, discharge, and agreement to hold harmless and fully indemnify discharges the Released Parties from any liability or claim that Camper may have against a Released Party for bodily injury or property damage, regardless of whether such injury or damage is caused in part by the act or omission of a Released Party. Notwithstanding the foregoing, nothing in this release shall be interpreted as requiring Camper to indemnify, defend, or hold harmless a Released Party from any liability, claims, demands, or causes of action caused solely by that Released Party’s gross negligence or willful misconduct. Camper agrees that the release, discharge, and agreement to hold harmless and fully indemnify set forth in this release are intended to be as broad and inclusive as permitted by law.

Assumption of the Risk. Camper understands that participating in Camp Amplify Inc. may involve activities that may be hazardous to the Camper and inherently dangerous risks, including but not limited to horseback riding, camp sports or amusement rides, swimming and traveling to and from camp or parks in vans or busses and Camper understands that there is a possibility of accidental or other physical injury or death to Camper or of loss or damage to Camper’s property. Camper hereby expressly and specifically assumes the risk of damage, injury, harm, or death in connection with such participation. In addition to any other risks posed by participating with Camp Amplify Inc., Camper understands that, despite any safety precautions being taken by Camp Amplify Inc., by participating with Camp Amplify Inc., there is a risk of potential exposure to COVID-19 or any other harmful virus or bacteria, which may result in illness or death.

Medical Treatment. Camper hereby grants permission for first aid and/or C.P.R. to be given to Camper in an emergency, as determined in the sole discretion of any employee, staff member, or agent of Camp Amplify Inc.  Camper further agrees that (a) Camper will be solely responsible for any medical costs or expenses or any loss, liability, or damage which may arise as a result thereof, (b) Camp Amplify Inc. (including its employees, staff members, and agents) may act on Camper’s behalf in securing medical treatment for Camper in the event of injury or illness to Camper, and (c) Camp Amplify Inc. may act on Camper’s behalf in accepting financial responsibility for any such first aid and/or other medical treatment secured for Camper (which responsibility shall be borne solely by Camper).

Photographs and other Media Release. Camper agrees to allow Camper to be photographed or recorded in other media, such as video or audio recordings, in connection with activities or events of Camp Amplify Inc. Camper understands and agrees that the photographs and/or other media recordings may be used to promote Camp Amplify Inc. and/or its services and events. Camper hereby irrevocably grants and conveys unto Camp Amplify Inc. all right, title, and interest in any and all photographic images and other media recordings taken of Camper during activities and events of Camp Amplify Inc., including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or other media recordings.  Camper understands and agrees that Camper is waiving all rights to privacy and ownership regarding the use of such photographs and other media recordings.

Parent or Legal Guardian Release: As the parent or legal guardian of the above Camper, I give my full consent to allow my child or ward to participate in the activities and events of Camp Amplify Inc. and its agents as described in the above release and waiver of liability. I have read and fully understand the terms and conditions in this release and waiver of liability. On behalf of myself and my child or ward, I agree to all the terms and conditions outlined in this release and waiver of liability.

The undersigned understand that the directors of Camp Amplify Inc. reserves the right to dismiss any camper (at the partner’s expense) who completely disregards the authority set in place at Camp Amplify Inc. or whose influence and conduct becomes in any way detrimental to the best interests of other participants and staff at Camp Amplify Inc.

Applicant Signature of Release (type your full name):

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