Machane Maimo

Camper Information

Name*

First Last

Camper Birthdate*

Gender*

Male
Female

School*

Grade entering Fall 2021*

Address*

Street Address City ZIP / Postal Code

Home Phone*

Parent/Guardian Information

Parent 1 Name*

First Last

P1 CELL*

P1 WORK

P1 Email*

Parent 2 Name*

First Last

P2 CELL*

P2 Work

P2 Email*

Emergency Contact Information

Please indicate TWO emergency contacts aside from parents/guardians listed above

EC1 Name*

First Last

EC1 Cell*

EC1 relationship to camper*

EC2 Name*

First Last

EC2 Cell*

EC2 relationship to camper*

Carpool Information

The following people, including parents/guardians, are permitted to pick up my child without advanced notice to the office*

Medical Information

List any known allergies and dietary restrictions here:*

type N/A if none

Please describe any medical issues we should be aware of:*

type N/A if none

Will the camper be taking any medication while at camp?*

Yes
No

Permission to dispense prescribed medication

I agree

I hereby authorize Machane Maimo to administer children’s Tylenol when my child (ren) or any child in my custody is ill and upon verbal authorization when called by the Academy.

All medications will be kept in the camp office and will be administered by Head Counselors, Camp Director, or Office Staff at the indicated times.

By consenting here, I grant Machane Maimo permission to dispense the aforementioned medication(s) to my child.

Permission to dispense prescribed medication

I agree

If your child is currently taking prescription and/or over the counter medications, please list along with the reason.
In order to dispense prescription medications during camp, contact the Director.

I hereby authorize Machane Maimo to administer children’s Tylenol when my child (ren) or any child in my custody is ill and upon verbal authorization when called by the Academy.

All medications will be kept in the camp office and will be administered by Head Counselors, Camp Director, or Office Staff at the indicated times.

By consenting, I grant Machane Maimo permission to dispense the aforementioned medication(s) to my child. Any change in the type or dosage of medication will promptly be reported to the Camp Office.

List any medications that your child will need administered at camp

Machane Maimo Registration

Camper Information

Parent/Guardian Information

Emergency Contact Information

Carpool Information

Medical Information

Release and Indemnification

Registration