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Zephyr Point Presbyterian Conference Center (ZPPCC)

Child/Youth Medical Release Form 2022

To attend, all campers must have completed this waiver and be paid-in-full by 7 days prior to the first day of camp.

EMERGENCY AUTHORIZATION AND LIABILITY RELEASE: This health history is correct so far as I know, and the person described above has permission to engage in all camp activities except as noted. I have familiarized myself with the camp program and events and understand that all activities are completely voluntary. I recognize the inherent risk of injury in camp activities and particularly, but not limited to: swimming, boating, archery, bounce houses, and water slides. I understand that ZPPCC has taken extensive safety measures in preparation for camp, including First Aid, CPR/AED, Lifeguard and USA Archery Instructor certifications for select staff, as well as making every effort to aid the safety of all camp participants. I also recognize that ZPPCC cannot ensure or guarantee that the participants, equipment, grounds and/or activities will be free of accidents or injuries. I am aware and have instructed my child in the importance of knowing and abiding by the camp's rules and regulations and do release ZPPCC from all liability for any injury to the camper. I understand that transportation to and from camp (and any liability thereof) is the responsibility of the camper, and not that of ZPPCC.

I give permission to the camp staff to (1) administer the camper’s routine medications, as needed medications, and over-the-counter medications for minor illnesses or discomfort; (2) provide appropriate first aid for minor injuries; and (3) seek further treatment from local physician or hospital if condition warrants. In the event I cannot be reached in an emergency, I give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for the camper named above. This completed form may be photocopied by the camp to have a second set available for transportation records and for ZPPCC’s office.

​COVID-19 AUTHORIZATION AND LIABILITY RELEASE: The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. As a result, federal, state, and local governments and agencies recommend social distancing and have, in many locations, limited the congregation of groups of people. We are doing everything we can to be compliant with all regulations and ensure your safety. We have put in place preventative measures to reduce the spread of COVID-19, but we cannot guarantee that you or family members will not become infected with COVID-19. For the latest Zephyr Point COVID-19 Policies and Procedures, visit https://www.zephyrpoint.org/programs/covid19/.

By entering the Zephyr Point property, you agree to the following:

On behalf of yourself and your minor children (if any), you hereby release, covenant not to sue, discharge, and hold harmless Zephyr Point Presbyterian Conference Center, its employees, agents, and representatives, of and from all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating to your presence on Zephyr Point property. You understand and agree that this release includes any claims based on the actions, omissions, or negligence of this organization, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after your presence on Zephyr Point property.

COVID-19 POLICY AGREEMENT: By initialing below, I acknowledge that I have read and will abide by Zephyr Point's Summer 2022 Program Safety Plan (v3). for the program I have registered for. I understand that these policies are subject to change based on federal, state, and local recommendations and mandates. It is my responsibility to monitor these changes between now and my arrival to Zephyr Point for said program. 



Please select who will be participating...
Minor
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First Camper's Name

First Name*

Last Name*
First Camper's Date of Birth*
First Camper's Information
Please select all weeks of participation: *
Week 1: June 13-17
Week 2: June 20-24
Week 3: June 27 - July 1
Week 4: July 5-8 (NO CAMP JULY 4)
Family Camp (July 3-8)
Week 5: July 11-15
Week 6: July 18-22
Week 7: July 25-29
Week 8: July 31 - August 5

Primary Home Address (Street, City, State, Zip) *

Gender (M/F/NB/Other) *

Age During Camp *

Grade in Fall 2022 *

List all individuals authorized to pick up your child from camp:

I allow my child to be able to return home from camp with the person(s) listed above. (I understand that a parent must give written permission to ZPPCC if they desire anyone other than themselves to transport campers home from camp. The alternate pickup person must have picture ID available at time of check out.)

First Camper's Signature*
Health History

Camper health and medical information needs to be made known to the camp. Camp personnel will hold this information in confidence. If insufficient space is provided, please attach additional paperwork if needed.

Allergies

If question is Not Applicable (N/A), please leave field blank.



Medical Allergies

Food Allergies or special dietary needs

Other allergies: (includes insect stings, hay fever, asthma, animal dander, etc.)
Does your child carry an epi-pen?*
No
Yes

If yes, what for?
Please check all that apply:
Recent Injury, illness, or infectious disease
Chronic or recurring illness
Ever been hospitalized
Ever had surgery
Frequent headaches
Head injury
Frequent ear infections
Ever passed out during or after exercise
Had seizures
Diabetes
ADHD/ADD
Heart Disease
If female, abnormal menstrual history
Eating disorder
Depression
Sleep problems
Psychiatric treatment
Bed wetting (recently)
Respiratory problems
Other

If yes to any of the above, please explain:

Are there any other medical conditions or restrictions that we should know of in order to best support your child? (if no, leave blank)

Are your child's immunizations up-to-date? *
Are all of your child's immunizations current?*
Yes
No
Unsure

Date of Last Tetanus *
Is your child fully vaccinated against COVID-19? (Fully vaccinated = 2 doses of Pfizer-BioNTech)*
Yes
No
Decline to State

NOTE: Proof of COVID-19 Vaccination is not required for participation in Camp Zephyr Day Camp.

Child Needs Assessment

ZPPCC desires to help meet each child’s physical, social, and spiritual needs during their week at camp. Please provide any additional information that may assist us to meet your child’s unique needs. Attach additional paperwork if needed.


Child Needs Assessment
  
If needed, attach additional documentation or care plans.
Valid file types: JPG, GIF, PNG, and PDF
Medications

List ALL medications including over-the-counter or non-prescription drugs taken routinely (please note if the medication is only taken at home). Bring enough to last the entire time at camp. Keep it in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage and the frequency of administration. All medications are administered by the Camp Nurse, and will be locked in a secure case. Please do not take your child off regular medicines while at camp. Attach additional paperwork if needed for more medications.

If question is Not Applicable (N/A), please leave field blank.


Medication #1 (Name, Dosage, Specific Times to be taken each day, Reason for taking)

Medication #2 (Name, Dosage, Specific Times to be taken each day, Reason for taking)

Medication #3 (Name, Dosage, Specific Times to be taken each day, Reason for taking)

Asthmatics (if applicable)

If your child uses an inhaler, please include in listed medications above.

If question is Not Applicable (N/A), please leave field blank.

I give my child permission to carry an inhaler to self-administer for asthma related incidents.
Yes
No, I prefer the camp health care personnel to keep my camper's inhaler and to help my camper determine when it is needed (recommended for day camp).
N/A

(If applicable) What triggers your child's asthma?
  
Attach additional paperwork, if needed.
Valid file types: JPG, GIF, PNG, and PDF
Health Insurance
Does your family carry health insurance?*
Yes
No

Carrier

ID Number

Group Number

Name of Doctor

Doctor's Phone Number
Media/Photography Release
I give permission for ZPPCC to use any photographs, video, or interview taken at camp to be used to illustrate, report, promote and advertise ZPPCC. (if you check “No," your child will be excluded from the group photo).**
Yes
No
Parent or Guardian's Email Address

Email*

Confirm Email*
Recreational Activity Release

While participating in Camp Zephyr, your child will have the opportunity to participate in a variety of recreational activities. Recreational activities, events, and use of the grounds include, but are not limited to, the following: Bounce House Activity, Inflatable Water Slide, Archery, Swimming, and Boating.

By completing this waiver, the undersigned parent or legal guardian and minor child (participating in camp activities) agree that they are physically able to participate in all camp activities based on a physician’s examination. If you would like to opt out of any number of these activities, please indicate below.

I give permission for my child to participate in all recreational activities offered during Camp Zephyr. (Note: We will never require any youth to participate in an activity that is outside of their comfort zone. By agreeing below, you are allowing permission for your child to participate should they desire to do so.)*
Yes, my child may participate in all recreational activities while at camp (DEFAULT - continue to next section)
No, I would like for my child to opt out of one or more recreational activities (answer next question)
I would like to OPT OUT of the following activities:
Swimming
Boating
Archery
Bounce House
Water Slide
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Please select all weeks of participation: *
Week 1: June 13-17
Week 2: June 20-24
Week 3: June 27 - July 1
Week 4: July 5-8 (NO CAMP JULY 4)
Family Camp (July 3-8)
Week 5: July 11-15
Week 6: July 18-22
Week 7: July 25-29
Week 8: July 31 - August 5

Primary Home Address (Street, City, State, Zip) *

Gender (M/F/NB/Other) *

Age During Camp *

Grade in Fall 2022 *

List all individuals authorized to pick up your child from camp:

I allow my child to be able to return home from camp with the person(s) listed above. (I understand that a parent must give written permission to ZPPCC if they desire anyone other than themselves to transport campers home from camp. The alternate pickup person must have picture ID available at time of check out.)

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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