Camp Shemesh Form 2024

Child/Family information

Today's Date: *

Gender *

Camper first/last name *

Hebrew Name

Birthdate *

Grade in August 2024 *

Address/ City/ State/ Zip *

Mother's Name *

Father's Name *

Mother's Cell *

Father's cell *

Mother's Work phone number

Father work #

Mother's Email *

Father's Email *

Emergency Contacts

Emergency Contact #1 Name: *

Emergency contact #2 *

Emergency contact #1 Phone # *

Emergency contact #2 phone # *

Relationship *

Medical Information

Can your child take ibuprofen *

Yes

Can your child take acetaminophen? *

Yes

Date of last Tetanus booster? * +

Name of Child's Pediatrician *

Additional Medical care providers

Address of Pediatric office *

Phone # of Pediatric office *

TN Immunization records: Mandatory for students enrolling in Pre-K 3, Kindergarten, and all new students.

Any medical conditions that would limit camper's activities

Food Allergies

Drug Allergies

Daily prescription drugs (Medication and Dosage)

Does your child have asthma? *

Yes

If you answered "yes" to the above question, please explain your child's method of treatment and plan for an asthmatic episode :

Will staff be administering daily medication?

Yes

No No

I give my permission for MHA to contact my child's medical provider(s) in the event of an emergency: *

clear

Transportation Information

I give permission for the following people to pick my child after school:

Additional Information

I acknowledge that I have received a copy of the Tennessee Department of Education Rules for Childcare and agree to accept and adhere to the policies and procedures. * *

clear

The faculty/ staff assigned responsibility for the care and education of my child has permission to access my child’s health records. * *

clear

I give permission for my child's photograph, digital or video recording, likeness, or artwork to be used in featured publications, web pages, or social media sites. Circulation of the materials could be worldwide and there will be no compensation to me or my child for the use. *

clear

Please provide any additional information you think we should know about your child:

clear