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McIntosh County Department of Leisure Services

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After-School and Summer Camp Forms

2004-2005 Summer Day Camp/After School/Christmas Break/Spring Break

Name: ________________________________________________ Age: _____________

Mailing Address: _________________________________________________________

Birthday: ____________________________ Grade: ________________

School: ___________________________________ Teacher: ______________________

Parents: _________________________________________________________________

Home Telephone Number: _____________________

Dad’ place of employment: ____________________________ Work #: _____________

Mom’s place of employment: __________________________ Work #: _____________

Emergency phone #: ______________________________________________________

Person (s) authorized to pick up: _____________________________________________



Medications: _____________________________________________________________

Allergies: _______________________________________________________________

In the event the child named above is injured or ill, I understand that the caregiver will attempt to contact the parent (s) or the legal guardian at the telephone numbers provided.

In the event that I or the others listed are not available, I give permission to the caregiver to provide first aid for the child named above and to take the appropriate measures, including contacting the Emergency Medical Service and arranging for transportation to the nearest emergency facility. At no time will the caregiver drive an ill or injured child to emergency medical facility unless accompanied by another adult.

Signature: ________________________________________ Date: ______________







Participant Health Information Form

Name of Activity: ____________________________________ Date: _____________

Name of Participant: ____________________________________________________

(Last) (First) (Initial)

Name of Parent/Guardian: ________________________________________________

(Last) (First) (Initial)

Address: _____________________________ City: ________ State: _______ Zip: _____

Home Phone #(912) ____________________ Work Phone #(912) __________________

Person to Contact in case of emergency _______________________________________

Relation__________________________________ Emergency Phone _______________

Participant’s Doctor _________________________ Phone ________________________

Child’s Physical Condition ______________________________________________________________________




List any physical or mental conditions or disease (epilepsy, heart murmur, rheumatic fever, etc.) Which your child may have or any other special medical information.

Does your child have any allergies to medicine, if yes please list the type of medicine.

We do not dispense drugs or any form of medication to our campers. This is the responsibility of the parent. Should there be a need for a child to receive medication it will be the sole responsibility of the parent to administer the medication.



Signature of Parent (s)/Guardian (s)______________________________Date______



Print forms and bring to the Office