EDUCATION — Camp cbg

emergency medical information and authorizations

Child's name:

Last name*:

First name*:

Birth date:

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  Adventurers   LIT
Break Camp

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:

Alternate Emergency Contact:

Medical History and 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.

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 applied during the day: Yes   No

3*. My child may partake of the peanut-free camp food based activities. Yes   No

4*. Does your child routinely require Medication? Yes   No
    Please list medical concerns (including medications, past health problems, etc.):

5. Limitations on activities:

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

7. 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.):

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.)

CAMPER CODE OF CONDUCT

• 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.

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