Camp Sign-Up General Information 1. I understand and accept that the 2021 Day Camp faces unique challenges, and to open safely, the Day Camp must meet CDC, NJ, local, and legal health guidelines, including ALL covid guidelines. 2. I understand and accept that all campers and staff must pass any daily health screenings to enter campgrounds. 3. I understand and accept that if denied entrance to campgrounds due to lack of meeting health screenings, refunds may be offered, however, attempts will be made to reschedule a denied camper at the next mutually available date. 4. I understand and accept that I may be called to pick up my camper when the camper is showing covid symptoms and will pick up my camper as soon as possible. 5. I understand and accept that if a camper is determined to be a health risk, that camper will be quarantined until a recognized person on the Registration Form has arrived. 6. I understand and accept that certain events that require shared resources (water, arts, play equipment, etc.) will be limited during the 2021 Day Camp. 7. I understand and accept that unlike previous Mendham Day Camps, the camp will be closed if the daily forecast predicts thunder/lightning. 8. I understand and accept that Day Camp may remain open if only rain is forecast. Staff and Campers will get wet and it will be the campers' family choice to attend. 9. I understand and accept that unlike previous Mendham Day Camps, the camp will not provide food or drink, other than water. Bottled water will be provided. I understand and accept all of the nine conditions above: Yes No CAMPER REGISTRATION INFORMATION First Name: Last Name: Gender: Male Female Grade (Sept '21): K 1 2 3 4 5 6 Guardian 1 (Name / Phone): Guardian 2 (Name / Phone): Approved for Pick Up 1: Approved for Pick Up 2: Approved for Pick Up 3: Walking / Biking home?: Pick up only Walk Bike Walk or Bike Approve to be photographed?: Yes No Weekly Registration Week 1: June 21-25 CLOSED/FULL: Week 2: June 28- July 2 CLOSED/FULL: Week 3: July 5 - July 9 CLOSED/FULL: Week 4: July 12 - July 16 CLOSED/FULL: Week 5: July 19-23 CLOSED/FULL: Week 6: July 26-30 CLOSED/FULL: Insurance Information (In case of emergency, this information will be required at any medical facility.) Name of insurance company: ID#: Group #: Name of Policy Holder: Relationship to Camper: MEDICINE DISPERSMENT: We are only able to administer emergency medications, specifically: Epi-Pens, Benadryl (for anaphylactic allergies), and inhalers. All other medications must be dispersed either at home, prior to arrival at camp, or on camp premises by a parent/guardian. Please note that campers who require an Epi-Pen for allergies must bring 2 to camp and that ALL medications MUST be in the original prescription box with the camper's name on it, his/her physician's name, a future expiration date, and the name of the pharmacy from which you obtained the medication. ALLERGIES/HEALTH ISSUES: Does your child have any of the following issues? If you answer "yes", please describe below the allergy/issue and the reaction seen. Provide a copy of any action plans to our Medical Director. Does your child have any food allergies?: Yes No Epi-Pen?: Yes No If yes, to which food(s)? Describe the reaction and indicate if an Epi-Pen was ever administered in the past: Does your child have any serious insect sting allergies?: Yes No Epi-Pen?: Yes No If yes, please describe the reaction and indicate if an Epi-Pen was ever administered in the past: Does your child have asthma?: Yes No Inhaler?: Yes No Does your child have latex allergies?: Yes No If yes, please describe the reaction: Does your child have a history of seizures?: Yes No If yes, please describe the reaction: Does your child have diabetes?: Yes No If yes, please describe the reaction: MEDICAL/PHYSICAL/EMOTIONAL CONDITIONS: Are there any physical, mental, psychological, or behavioral conditions requiring medication, treatment, or special restrictions or considerations while at camp of which we should be aware to ensure your child's fullest enjoyment of their camp experience? Please describe, including any special accommodations necessary. Please note that it is your responsibility to supply any necessary medical equipment that relates to a specific medical condition. Are there any camp activities from which the camper should be exempted for health reasons?: Do you want to be notified immediately during the camp session for minor injuries (e.g. scrape, non-allergic bee sting, bloody nose, sliver) that do not limit participation in the program?: Yes No RELEASE OF LIABILITY & AUTHORIZATION FOR TREATMENT: I recognize and acknowledge that there are certain risks of physical injury to campers and I agree to assume the full risk of any injuries, damages or loss, regardless of severity, which my minor child/ward or I may sustain as a result of participating in any and all activities connected with or associated with Mendham Borough Day Camp. I agree to waive and relinquish all claims my minor child/ward or I may have against Mendham Borough and its officers, agents, volunteers, and employees as a result of participation in the program. I do hereby fully release and discharge the Mendhab Borough and its officers, agents, volunteers, and employees from any and all claims from injury, damage or loss with the activities of the program(s). I further agree to indemnify and hold harmless and defend the Mendham Borough and its officers, agents, servants, and employees from any and all claims resulting from injuries, damages, and losses sustained by me or my minor child arising out of, connected with, or in any way associated with the activities of the program(s). I hereby give permission to Mendham Borough Day Camp to provide first aid treatment for minor injury or illness and to provide and arrange for emergency treatment of other illnesses. In the event of any emergency, I authorize the Mendham Borough Day Camp to secure from any licensed hospital, physician, and/or medical personnel any treatment deemed necessary for me or my minor child/ward's immediate care and agree that I will be responsible for payment of any and all medical services rendered. I understand that this authorization includes that transporting of my child by ambulance, if necessary, to the nearest medical treatment facility or to the hospital, if I am unable to be reached first. I give permission to Mendham Borough Day Camp to photocopy this form to accompany camper for medical treatment and for trips off campgrounds.