EDUCATION — Camp cbg

Camp CBG Emergency/Health History Form

Please give us your emergency contact and carpool information below. Agreement to the code of conduct listed below is required. Required fields are marked with an asterisk (*).

A confirmation email will be mailed to you within 24 hours. Thank you.

emergency medical information and authorizations

Child's name:

Last name: *
First name: *
Birth date:
Home address:
Person who registered child: *
Email registration confirmation to: *

My child is enrolled in (please check appropriate box):*

My First Camp 2  My First Camp 3   Green Sprouts  
Green Thumbs   Explorers  Rovers   Adventurers
LIT   Break Camp   Bloomin' Garden Strollers

I consent that my child/ren may be photographed, and to the use of such photographs in future Chicago Botanic Garden publications and promotional materials.* Yes   No

Person to Contact in an Emergency:

Name: Relationship:
Home Phone: Cell Phone:
Work Phone:

Alternate Emergency Contact:

Name: Relationship:
Home Phone: Cell Phone:
Work Phone:

Emergency Authorizations

I attest that my child is in good physical and mental health. Any special considerations are indicated below. In case of accident or illness, I hereby give permission that my child may be given emergency treatment and, further, I authorize and consent to the administration of any and all medical, dental, and surgical examinations or operations and treatment or all other related care, including the administration of drugs, tests, anesthesia, and/or blood transfusions to the above named child that may be ordered by the medical care provider in attendance at the facility deemed necessary for medical treatment. I hereby consent to the release of medical report(s) to any medical care provider and consent to the admission of the above-named child to a hospital. I agree to be responsible for any medical expenses incurred on behalf of my child.

Parent/Guardian Name: *

Emergency Authorizations

IMPORTANT: Please describe any special health considerations including, but not limited to, allergies, physical or behavioral conditions that may affect your child's participation in this camp in the section below.

1. What allergies does your child have? Please be specific as to the severity and treatment. If none, indicate "none" in the field below.*

2. My child may have sunscreen and/or Deet-free bug spray applied by Camp CBG staff during the day: Yes   No
3. My child's immunizations (as required by school) are up to date:* Yes   No
  Please list the date of your child's last tetanus shot:*
4. My child may partake of the nut-free camp food-based activities.* Yes   No
5. Please list all of your child's current medications (both prescribed and over-the-counter):*

6. Please describe any physical, mental, behavioral, or psychological conditions requiring medication, treatment, or for which your child is under the care of a doctor or health practitioner:*

7. Limitations on activities (including diet restrictions):

8. Behaviors of which staff should be aware, and how you handle this behavior:

9. Is there any additional information you can provide to ensure a positive
camp experience for your child?:

carpool/pick-up authorizations

The following individuals are in my carpool and are authorized to pick up my child from camp. (If you are not participating in a carpool, list those authorized to pick up your child.):

Name: Relationship:
Cell Phone: Day Phone:


Name: Relationship:
Cell Phone: Day Phone:


Name: Relationship:
Cell Phone: Day Phone:


Name: Relationship:
Cell Phone: Day Phone:

NOTE: Written notification by parents or guardian MUST be given for pick-up by someone other than persons listed. If your carpool changes before your child's camp session, complete a new form. Please let us know in advance if there are any issues regarding pick-up/drop-off of which we should be aware (custody disputes, etc.).


• Campers will treat their fellow campers, instructors, and volunteers with respect.
• Campers will follow directions and stay with their group.

Please read and discuss these expectations with your child. In the event that a camper does not follow the Code of Conduct, or his or her behavior endangers other campers or interferes with an instructor's ability to provide programming, the instructor will inform the parent and the Manager of Camp Programs at pick-up or through a phone call. If a second incident occurs, parents may be asked to accompany their child during camp, or withdraw from camp. Refunds will not be given for behavior-related withdrawals.

I have read and discussed this Code of Conduct with my child. (Please check box.)*

I understand that by completing and submitting this Medical Form via electronic transmission that I acknowledge the above statements and my submission of this form on-line shall substitute for and have the same legal effect as an original form signature.

By registering for Camp CBG, I agree to the terms and conditions as outlined in the Camp Guidelines. 



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