AMT Camper Registration

Camper Registration Form
Camper
First Name:*
Last Name:*
Primary Role*
Date of Birth:*
Gender:*
Pronoun*
Ethnicity*
Race*
Phone:*
Type	Home Cell Work Other
Email Address*
Address Line 1:*
Address Line 2:
City:*
State:*
Zip Code:*
School (Fall)*
Grade Now*
Grade (Fall)*
T-Shirt Size:*
Girls must not alter their shirts in any way before camp. Girls can sign shirts only on Friday.
Are you a registered girl scout?*
Troop # (0 if none)*
Individually Registered Member?*
Camp Buddy
Camp Buddies are optional. Each camper may only have one buddy. Buddies must be mutual and in the same grade.
Buddy First Name:
Buddy Last Name:
Parent/Guardian #1
First Name:*
Last Name:*
Phone:*
Type	Home Cell Work Other
Alt Phone:
Type	Home Cell Work Other
Alt Phone:
Type	Home Cell Work Other
E-Mail:*		Valid e-mail is required
Parent/Guardian #2
Not required, however if name is put in a field at least one phone number is required.
First Name:
Last Name:
Phone:
Type	Home Cell Work Other
Alt Phone:
Type	Home Cell Work Other
Alt Phone:
Type	Home Cell Work Other
E-Mail:
Emergency Contact #1
If we are unable to contact parent/guardian, we will contact the emergency contact
First Name:
Last Name:
Relationship to Camper:
Phone:
Type	Home Cell Work Other
Alt Phone:
Type	Home Cell Work Other
Emergency Contact #2
If we are unable to contact parent/guardian, we will contact the emergency contact
First Name:
Last Name:
Relationship to Camper:
Phone:
Type	Home Cell Work Other
Alt Phone:
Type	Home Cell Work Other
Bus Information
Bus Preference*
Carpool Buddies
Carpool Buddy 1 (First Name):
Carpool Buddy 1 (Last Name):
Carpool Buddy 2 (FULL NAME):
Carpool Buddy 3 (FULL NAME):
Carpool Buddy 4 (FULL NAME):
Racial Background and Ethnicity
Acceptance and participation in day camp is the same for everyone without regard to race, color, or national origin. As an equal opportunity organization, Girl Scouts is dedicated to diversity and fully supports the right of equal access for girl and adult members with disabilities. Girl Scouts of Oregon and Southwest Washington makes every reasonable effort to ensure this access. We encourage you to voluntarily provide the following information on racial background and ethnicity. This information will be used by Girl Scouts of the USA for statistical purposes and to help improve outreach efforts and advance the Girl Scout Movement. The registrants racial background is (please check as many as apply)
American Indian or Alaskan Native
Black or African American
Hawaiian or Pacific Islander
Asian
White
Other		Please specify below
Do not wish to provide
The registrant`s ethnic background is (please check one)
Hispanic or Latina
Not Hispanic or Latina
Do not wish to provide
Please list any medications taken on a daily basis, including over-thecounter medications:
Please specify:
Health History & OTC Medications
Family Medical/Hospital Insurance Carrier
Policy or Group #
Health History Record (Check all that apply)
Chronic or recurring illnesses:
Heart Defect / Disease
Seizures
Bleeding / Clotting
Asthma
Diabetes
Other (if checked, specify below)

Any restrictions concerning physical activities?
Check One*
Please describe any conditions:
Allergies: (If checked, include additional information)
Food, Nuts
List all food/nut allergies
Food Allergy Severity (some/all foods listed)	Severe - Any exposure requires immediate medical attention Other - Give details below
Food Allergy Notes (details for each food)
Insect Stings
List insect allergies
Insect allergy notes
Medicine / Drugs
List medicine/drug allergies
Medicine/drug allergy notes
Other Allergies
List/describe other allergies
Tetnus?*
Date of last booster? (year)
Please list any medications taken on a daily basis, including over-thecounter medications:
Any other relevant health concerns:
Camper Only - Over-the-Counter Medications
According to our Day Camp Protocols and Health Care Procedures, our health care staff can administer certain types of over-the-counter (OTC) medications. In order for your camper to be able to receive these, we need to have a parent/guardian signature. Check box if camper MAY RECEIVE any of the following OTC medications:
Acetaminophen (Tylenol or generic)
Ibuprofen (Advil or generic)
Diphenhydramine (Benedryl or generic)
Non-medicated cough drops
Insect repellent (may contain up to 15% DEET)
OTC Antacid (Tums)
Calamine lotion
Antibiotic Ointment
Sunscreen (without PABA, minimum SPF 30)
Hydrocortisone
Weight of child for dosage purposes:
(Unchecked boxes means camper MAY NOT receive that medication.)
Permission and Release - Electronic Signature
As a parent/legal guardian I give permission for the registrant to participate in all phases of camp. I understand and agree to cooperate with all camp and Girl Scout regulations. I will not allow registrant to attend camp if not in good physical condition. I/we verify that this health history is complete and accurate. My child has permission to engage in all prescribed activities, except as noted by me. In case of illness or injury, I/we give permission for her/him to receive first aid and to receive emergency treat- ment from a licensed physician, emergency medical services or other health care professional. It is understood that all reasonable efforts will be made to contact the parent or guardian. I/we verify my child has my permission to receive the above-mentioned over-the-counter medications. By typing my name below and clicking “I agree” button, I acknowledge that I fully understand and agree to all provisions of this Permission and Release and that this action is equivalent to signing a printed copy of the Permission and Release. I also agree to complete this registration electronically.
Name:*		Provide complete name
I AGREE*
I wish to opt out of media permission at this time.
I wish to opt out of GSUSA/GSOSW emails/texts at this time.
Submit Form - please only click the submit button once
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