Camper Application What organization referred you to Camp Amplify? Referring Organization Name Camper Information First Name Middle Name Last Name Date of Birth Gender Family Information Personal Information Family Role (ex: Mother, Legal Guardian, etc.) First Name Middle Name Last Name Email Profession Primary Address Home Type (ex: House, apartment, etc.) Street Address City State Zipcode Phone Number 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: 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: 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: 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: YesNoDEPRESSION If yes, provide details: YesNoANXIETY If yes, provide details: YesNoBI-POLAR / PSYCHO - SOCIAL DISORDER If yes, provide details: Medical History - Emergency Contacts Relationship Contact Full Name Contact Daytime Phone Contact Evening Phone Contact Cell Phone Relationship Contact Full Name Contact Daytime Phone Contact Evening Phone Contact Cell Phone Relationship Contact Full Name Contact Daytime Phone Contact Evening Phone Contact Cell Phone 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. Medication Route of Administration Strength Check all that apply: BreakfastLunchDinnerBedtimeAs Needed Special Instructions or Comments Medication Route of Administration Strength Check all that apply: BreakfastLunchDinnerBedtimeAs Needed Special Instructions or Comments Medication Route of Administration Strength Check all that apply: BreakfastLunchDinnerBedtimeAs Needed Special Instructions or Comments Medication Route of Administration Strength Check all that apply: BreakfastLunchDinnerBedtimeAs Needed Special Instructions or Comments Medical History - Insurance Name of Insurance Company: Policy Number: Insurance Company phone number: Your doctor's name: Your doctor's phone number: Miscellaneous Information 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 medical, liability and image 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 Medical and Liability and Image Release The undersigned represents to Camp Amplify Inc., that he/she is the legal guardian and natural parent or the legal guardian of the above named child; and the undersigned does hereby consent to such minor taking part in the Camp Amplify Inc., with full understanding that insofar as such activity will involve but is not limited to traveling to and from camp or parks in vans or busses, eating food prepared by camp staff or local restaurants, swimming, horseback riding, camp sports or amusement rides; which could include, low & high ropes courses, lakes, pools, or other, and that there is always the risk of injury, illness, loss, death, and possible consequent expenses for the medical, diagnostic, and curative treatments, and incidental loss and expense, and the undersigned does for him/herself and for and on behalf of such minor assume the risk of such expense and does hereby wholly release Camp Amplify Inc. and any representative from any responsibility or liability; and waives any claims or causes of action against it or its agents that might rise on account of loss, injury, death, or expense occasioned by any sort of accident or illness (such as coronavirus) or any other circumstances involving such child, and agrees to hold harmless in event any such claim should arise; and the undersigned agrees to abide by the rules and regulations, supervision and discipline set applied by Camp Amplify Inc. and its agents, and does hereby authorize Camp Amplify Inc. or its representatives or other agents to arrange for any needed medical treatment or x-rays, and hold harmless Camp Amplify Inc. from any such expenses. The undersigned will reimburse Camp Amplify Inc. fully or furnish payment or insurance for any such permission is also given to the camp nurse or doctor to administer over the counter medication to the above-named child as needed. The undersigned also gives permission to Camp Amplify Inc. to use any image, video or written material that the above-named child is in or wrote. Images and videos will be used for the sole purpose of promoting the camp and not for financial gain. 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): This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Δ
