WRAP IT UP HEALTH FORM

Parent or Guardian Name

First Name

Last Name

Name of Second Parent or Guardian

First Name

Last Name

Phone of Second Parent or Guardian

(###)

###

####

Emergency Contact if Parents or Guardians Cannot be Reached

First Name

Last Name

Phone of Emergency Contact

(###)

###

####

Medical Insurance Provider (required)

Policy Number of Insurance Provider (required)

Medical Waiver

By electronically signing this document below, I hereby verify that the below information is complete and accurate to my knowledge. I hereby grant permission for my child/children to receive first aid and emergency treatment by Canby Grove/JumpIn NW Program personnel in the event of injury, or by the hospital emergency room, for a life-saving decision if I cannot immediately be reached. I voluntarily waive any claim against Canby Grove/JumpIn NW personnel, or other persons transporting my child, against all liability, claims, damages, attorney fees, or expenses arising out of or in connection with any activities of the above-mentioned organization.

Photography Release

If your child is in a photograph taken by Canby Grove/JumpIn NW designated staff the photograph may be used in publications on-line or in print for advertising purposes. Canby Grove/JumpIn NW will not include the name of campers on any publications or sell merchandise with your child's/children's photo. Canby Grove will not sell your child's/children photo with any business. It is for the exclusive use of Canby Grove/Jump-In NW publications and advertising. If you choose not to have your child allowed in publications they will not be in group photos when taken and will have a red circle on their tag so the photographer knows not to take photos of that child.

Camper Name

First Name

Last Name

Age

Birth Date

YYYY

List of allergies and your child’s reaction to that allergy.

Please list medical, mental, or behavioral health issues that we should be aware of in order to safely care for your camper while attending Day Camps.

These may include, Diabetes, Seizures, Asthma, Autism, or other health considerations.

Date of last Tetnus

YYYY

Camper #2 Name

First Name

Last Name

Birth Date

YYYY

Age

List of allergies and your child’s reaction to that allergy.

Date of last Tetnus

YYYY

Please list medical, mental, or behavioral health issues that we should be aware of in order to safely care for your camper while attending Day Camps.

These may include, Diabetes, Seizures, Asthma, Autism, or other health considerations.

Camper #3

First Name

Last Name

Date of Birth

YYYY

Age

List of allergies and your child’s reaction to that allergy.

Date of last Tetnus

YYYY

Please list medical, mental, or behavioral health issues that we should be aware of in order to safely care for your camper while attending Day Camps.

These may include, Diabetes, Seizures, Asthma, Autism, or other health considerations.

Camper #4

First Name

Last Name

Date of Birth

YYYY

Age

List of allergies and your child’s reaction to that allergy.

Date of last Tetnus

YYYY

Please list medical, mental, or behavioral health issues that we should be aware of in order to safely care for your camper while attending Day Camps.

These may include, Diabetes, Seizures, Asthma, Autism, or other health considerations.

WRAP IT UP HEALTH FORM

THE PERFECT HOLIDAY PARTY VENUE

Looking for a venue to host your Company or Family Christmas Party this year? How about Canby Grove?

Contact Us:

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