WSSB Programming Camp Registration

July 24-27, 2012

Class: 

summer camp!

Name:              Gender: 

Address:      

City:               State:   Zip:

Date of Birth:     Age:

Home Phone (Including Area Code): 

Parent or Legal Guardian:

Work Phone:   Cell Phone:

Emergency Contact (Different than above):     

Emergency Telephone (Including Area Code): 

 


Educational Information

 

Grade Level Entering for September 2012:

Reading Medium (Braille, Large Print, Regular Print, Auditory):

Reading Grade Level:

School District:         

Vision Teacher:        

Does this student use a long cane for travel? 

Does this student have a mobility instructor?    Name:    

Does this student use low vision aides?            Describe:

 


Medical Information

 

Primary Physician:

Telephone Number (Including Area Code):  

Policy Name/Group Number:

Telephone Number (Including Area Code): 

 

Type of Visual Impairment:

Acuity:

Does the Student Have any Physical Impairment other than the Visual Impairment?  

    Describe:

Other Medical Conditions:

 

 

Immunizations (Enter dates)

DPT

POLIO MMR1 MMR2 HEP B
1. 1. 1. 1. 1.
2. 2.     2.
3. 3.     3.
4. 4.      

 

 

Current Medications:

Name of medication

Dosage Time to be administered Reason for medication
1.
2.
3.
4.
5.

NOTE: MEDICATIONS MUST BE IN THE ORIGINAL CONTAINER AND PRESCRIBED BY AN MD, PA OR NP.

Permission to administer over the counter medication during attendance? (I.E. Tylenol, cough syrup)

Please list any restriction regarding over the counter medication:

Allergies (medication/food):

Special Diet (Include Physician's order):

Any history of seizures? If yes, please describe


Permissions and Releases

My Child will Live on Campus during the time of the course.

I authorize WSSB personnel to provide emergency medical care for my child in the case of illness or accident in the event I am unable to be contacted.

I agree to accept responsibility for payment of any medical care for my child that may be necessary during the week.

I authorize WSSB to include my child in any TV/media coverage:

I understand that my child will be subject to the following rules:
 1.    Students will be allowed off campus only when accompanied by an adult staff member. NO Exceptions.
 2.    No tobacco products - no smoking - no knives - no weapons - no exceptions.
 3.    Any student found with alcohol, controlled substances or drug paraphernalia will be sent home immediately at the parent's
        expense.
 4.    All students will participate in leisure and recreational activities as planned.
 5.    Students will follow the directions of the staff members.

Parent/Guardian Signature:

Email Address:


NOTE: BEFORE you press "Submit" Please print this screen for your records! (please be sure to set page layout to landscape to get all details)