Zootopiaregistrationform

Join Us For Week of Wild Adventure at
August 18-23
August 25-30
Camp Schedule: A Zootopia week runs from Monday morning at 9am until Saturday at 10am. Currently Zootopia does not have transportation options so you must drop off and pick up your camper. Age Groups: Campers will be divided into two age groups: 7-11 and 12-14. The two groups participate separate and together at various times. Camp Activities: Your camper will participate in a wide variety of educational activities that include but are not limited to: wildlife presentations, up close meet/greet and touch opportunities with some of our safer animal friends, art and craft projects, wildlife and eco based science projects and educational discussions. In between learning about wildlife, ecosystems and green living your camper will have the opportunity to expend some of that summer energy participating in the many physical activities camp has to offer: Swimming, Go Carts / Power Wheels, Climbing Wall, Challenge Course, Zip Line, Sports Field, Ball Field, Mini Golf, Ping Pong, GaGa, Carroms, Tetherball, Basketball, Volleyball, Archery, Drama/Skits, Hiking, Nature, Frisbee Golf, Mini Golf, Game Room, Barn Activities, Cooking, Socco, Broom Ball, T-Ball, Soccer, Flag Football, Kickball, Field Hockey, Capture the Flag, Handball, Relay Races, Parachute, Water Games, Cooking Projects, Otter Ball, and many other activities. Accommodations: Your camper will enjoy the fun of group tent camping in one of the 6 tents available. Delicious meals are served in an air-conditioned dining hall. Each day the summer dirt will be washed off in a full shower facility. And…no camp experience would be complete without an evening around the campfire. Camp Tuition: Tuition is $800 per session plus a $50 registration fee. A non-refundable deposit of $400 is required to guarantee registration. The balance is due 14 days prior to sessions start. You may pay with a credit card online at: http://www.zootopia.org. We also offer a Sibling Discount: $100 off each of the second, third and fourth campers. Mail or Fax this completed form (with payment and Health Forms) to: Zootopia Registration PO Box 11325 Burbank, CA 91510-1325 Fax: 818-450-0307 Camper Information (Please fill out form completely) Camper 1 Name ______________________________________ Gender ________ DOB _____/_____/_____ Address __________________________________ City ______________State ______Zip _______ Home Phone _________________________ Camper 2 Name ______________________________________ Gender ________ DOB _____/_____/_____ Address __________________________________ City ______________State ______Zip _______ Home Phone _________________________ Parent/Guardian Information Parent/Guardian #1_______________________________Relation_________________________________ Address________________________________________________________________________________ Phone#1______________________________ Phone#2_____________________________ E-mail Address______________________________________ Parent/Guardian #2_______________________________Relation_________________________________ Address________________________________________________________________________________ Phone#1______________________________ Phone#2_____________________________ E-mail Address______________________________________ Emergency Contact Information Name (contact during camp hours)___________________________________Relation_________________ Day Phone______________________________ Cell Phone____________________________________ Session Information Please register my child into the following camp session: Session #1 __________August 18-23 (drop-off Monday at 9am, pick-up Saturday at 10am) Session #2___________August 25-30 (drop-off Monday at 9am, pick-up Saturday at 10am) Scholarship___________(As a scholarship donor we ask that you contact us with the name and contact info of the recipient as soon possible. Sessions must be selected by scholarship recipient no later than 14 days prior to the start of that session. Sessions are available on a first come first serve basis.) Amount paid__________ Form of payment: Cash ______ Check _______ Credit Card_______ Balance due__________ Date balance due___________ 1. A $400 non-refundable deposit per session is required to guarantee your registration 2. Refunds of 50% will only be given if we receive written notice 14 days prior to the start of that session 3. No refunds will be given if a camper withdraws from camp for any reason once the session has started 4. No refunds will be given if a camper is dismissed from camp 5. Schedule changes, moving your camper from one session to another, will only be granted with a 30-day written notice prior to the session that is being switched out of. Switching to a different session is available on a first come first serve basis. Agreement In case of medical emergency, I hereby grant permission to Zootopia and its staff to seek medical attention for my child from either our stated physician OR a physician selected by the camp director or their representative to order x-ray, routine tests, and treatment for the health of my child. In the event that I cannot be reached in an emergency, I give permission to the physician selected to hospitalize, secure treatment for, and to order injections for my child. Zootopia and related organizations may use pictures of my child in their promotional materials, including both printed and electronic media. My child has permission to engage in all camp activities except as noted. In consideration of the named camper's being permitted to participate in Zootopia camp activities, we, the parents or legal guardians of the camper, on our own behalf and on behalf of the camper (hereinafter “Releasors”), hereby acknowledge and agree that we understand and fully appreciate the risk of injury involved to the camper in participating in camp activities. The Releasors nevertheless hereby release, waive, and discharge Zootopia, its officers, employees, agents, counselors, representatives, and premises owners and operators where camp activities take place (hereinafter “Releasees”) from all liability to the Releasors for any loss or damage, and any claims or demands on account of injury to the camper caused in any way by the negligence of the Releasees or otherwise while the camper is participating in any way in any of Zootopiaʼs camp activities. The Releasors hereby agree to indemnify and hold harmless the Releasees, and each of them, for any loss, liability, damage, or costs and expenses including attorneysʼ fees they incur due to the camperʼs participation. It is the express intention of the Realesors to exempt and relieve the Releasees from any liability for personal injury, property damage, or wrongful death caused by the Releaseeʼs own negligence related in any way to the participation of the camper in Zootopia camp activities. The undersigned acknowledges that he or she is fully aware of the legal consequences of signing this application containing the express waiver and release of liability. Camp Standards We are committed to providing a fun, exciting and educational program. However, we are also committed to safety. To assist us in delivering a safe program for the animals and public, please read and sign that you have gone over this with your camper and understand the following: 1. No violent or dangerous behavior will be tolerated. We reserve the right to suspend or expel any child who violates this rule without refund of tuition. 2. Campers are expected to clean up after themselves in the rooms and on the playground. 3. Campers may not leave the designated lunch area until given permission to do so. 4. Campers may not leave the camp grounds without direct supervision. 5. Campers may not eat inside the classroom unless the camp counselor gives approval. 6. Campers may not be in a classroom alone. 7. Abusive or foul language, threats of violence or bodily harm towards anyone, is cause for disciplinary action and/or immediate dismissal from Valley Trails Summer Camp without refund of tuition. 8. Campers may not leave the group without permission from the counselor. 9. Gum chewing is not allowed at any time on camp grounds or in the classroom. My signature below indicates that I have read and fully agree with all policies and information stated above and have gone over the rules with my camper. Parent/Guardian Signature ___________________________________ Date ________________
Dates will attend camp: from ______________to_____________ Camper Name: _____________________________________________________________ Developed and reviewed by: American Camp Association, Male Female Birth Date ____________ Age on arrival at camp: ________ American Academy of Pediatrics Council on School Health, & To Parent(s)/Guardian(s): Please follow the instructions below. Attach additional information if needed.
Mail this form to the address below by _______ (date)
Complete pages 1, 2 and 3 of this form (FORM 1) and make a copy.
Send the original, signed FORM 1 to camp by the requested date.
Complete the top of FORM 2 (CAMPER HEALTH-CARE RECOMMENDATIONS) and provide the
copy of FORM 1 with FORM 2 to your child’s health-care provider for review and completion.
After it has been completed and signed by your child’s health-care provider, return FORM 2 to
camp by the requested date.
Camper Home Address: ______________________________________________________________________________________________________ Parent/guardian with legal custody to be contacted in case of illness or injury: Name: ____________________________ to Camper: ________________Preferred Phones: (______) ________________(______)_________________ Home Address: _____________________________________________________________________________________________________________ (If different from above) Street Address Second parent/guardian or other emergency contact: Name: ____________________________ to Camper: ________________Preferred Phones: (______) ________________(______)_________________ Additional contact in event parent(s)/guardian(s) can not be reached: Name(s): __________________________ to Camper: ________________ Preferred Phones: (______) ________________(______)_________________ Allergies: No known allergies. This camper is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other
(Please describe below what the camper is allergic to and the reaction seen.)
Diet, Nutrition:
This camper eats a regular diet. This camper eats a regular vegetarian diet. This camper has special food needs. (Please describe below.)
Restrictions:
I have reviewed the program and activities of the camp and feel the camper can participate without restrictions. I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations. (Please describe below.)
Medical Insurance Information:
This camper is covered by family medical/hospital insurance Yes No Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable.
Insurance Company______________________________ Policy Number___________________________ Subscriber_____________________________________ Insurance Company Phone Number (______) ___________________ Parent/Guardian Authorization for Health Care:
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in
all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests,
and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my
permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on
this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a
copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.
Parent/Guardian __________________________________________________________________Date: to Camper: _______________________ If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance. Page 1/4
Camper Name: ________________________________________________ Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Immunization History: Provide the month and year for each immunization. Starred ( ) immunizations must be current. Copies of immunization forms
from health-care providers or state or local government are acceptable; please attach to this form.
(chicken pox) Date: Meningococcal meningitis
If your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not
being fully immunized.
Parent/Guardian: ______________________________________________________________Date: to Camper: __________________________ Medication:
This camper will not take any daily medications while attending camp. This camper will take the following daily medication(s) while at camp: "Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Please review camp
instructions about required packaging/containers. Many states require original pharmacy containers with labels which show the camper’s
name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp.
Lunch Dinner Bedtime Other time:_____________ Lunch Dinner Bedtime Other time:_____________ Lunch Dinner Bedtime Other time:_____________
The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury.
Cross out those the camper should not be given.
Diphenhydramine antihistamine/allergy medicine (Benadryl) Dextromethorphan cough syrup (Robitussin DM) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Copyright 2008 by American Camping Association, Inc. Camper Name: ________________________________________________ Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses General Health Histor
y: Check
"Yes" or "
No" fo
r each st atement. Exp
lain “Ye
s” answers below.
1. Ever been hospitalized? …………………………. Yes No 2. Ever had surgery? . …………. Yes No 12. Passed out/had chest pain during exercise? ….……………. Yes No 3. Have recurrent/chronic illnesses? .……….… Yes No 13. Had mononucleosis ("mono") during the past 12 months?. Yes No 4. Had a recent infectious disease? . …………. Yes No 14. If female, have problems with periods/menstruation?.……. 5. Had a recent injury? . …………. Yes No 15. Have problems with falling asleep/sleepwalking? . 6. Had asthma/wheezing/shortness of breath?. 16. Ever had back/joint problems?…….……….……………. Yes No 7. Have diabetes? . …………. Yes No 17. Have a history of bedwetting?………………….……………. Yes No 18. Have problems with diarrhea/constipation?………………. 9. Had headaches? …………………………………. Yes No 19. Have any skin problems?……………………. Yes No 10. Wear glasses, contacts, or protective eyewear? 20. Traveled outside the country in the past 9 months?. Yes No Please explain “Yes” answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited
and dates of travel.
Mental, Emotional, and Social Health: Check "Yes" or "No" for each statement.
1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)? ………………………. 2. Ever been treated for emotional or behavioral difficulties or an eating disorder?……. 3. During the past 12 months, seen a professional to address mental/emotional health concerns?……….…………………………………. Yes No 4. Had a significant life event that continues to affect the camper’s life?. Yes No (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others) Please explain “Yes” answers in the space below, noting the number of the questions. The camp may contact you for additional information.
Health-Care Providers:
Name of camper’s primary doctor(s): ____________________________________________________ Phone: (________) _______________________ Name of dentist(s):___________________________________________________________________ Phone: (________) _______________________ Name of orthodontist(s):_______________________________________________________________ Phone: (________) _______________________ What Have We Forgotten to Ask? Please provide in the space below any additional information about the camper’s health that you think important or
that may affect the camper’s ability to fully participate in the camp program. Attach additional information if needed.
Parents/Guardians: STOP here. The rest of this is form is completed when the camper arrives at camp. Keep a copy for your records.
Copyright 2008 by American Camping Association, Inc. Camper Name: ________________________________________________ Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Individual Health Record (For Camp Use Only)
Initial Screening
Date/Time: _________
Initials: ____________
Screening has been conducted according to camp protocol and significant findings noted as follows:
A. Any signs/symptoms of illness or injury upon arrival?. No Yes as noted below B. History of exposure to communicable disease?. No Yes as noted below C. Additions or corrections to information on this health history?. No Yes as noted below D. Medication given to health-care staff?. E. Any signs/symptoms of head lice?. No Yes as noted below Provider notes: (date/time/initial all entries) _____________________________________________________________________________
____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Exit Note: Check one of the following:
Left camp this day with no reported illness or injury symptoms. Left camp this day with the following problem/concern: ________________________________________________________________________________________________________________ This person was told about the problem and instructed about follow-up as noted above: __________________________________________ Date/Time: ___________ Initials: __________ Copyright 2008 by American Camping Association, Inc. To Parent(s)/Guardian(s): Complete this section and give this form (FORM 2) and a copy of your
completed CAMPER HEALTH HISTORY FORM (FORM 1) to your child’s health-care provider for review.
Developed and reviewed by: American Camp Association, Dates will attend camp: from ______________to_____________ American Academy of Pediatrics Council on School Health, & Camper Name: _____________________________________________________________ Male Female Birth Date ____________ Age on arrival at camp ________ Mail this form to the address below by _______ (date)
Camper home address: ________________________________________________________ ____________________________________________________________________________ Custodial parent(s)/guardian(s) phone: (_______)______________ (_______)____________ Parent(s)/guardian(s) stop here. Rest of form to be completed by medical personnel.
The following non-prescription medications are Medical Personnel: Please review the CAMPER HEALTH HISTORY FORM (FORM 1) and complete all
commonly stocked in camp Health Centers and are remaining sections of this form (FORM 2). Attach additional information if needed.
used on an as needed basis to manage illness and injury. Medical personnel: Cross out those items the
Physical exam done today: Yes No (If “No,” date of last physical: ___________)
camper should not be given.
ACA accreditation standards specify physical exam within last 24 months.
Weight: _______ lbs Height: _____ft_____in Blood Pressure_______/_______ Pseudoephedrine (Sudafed) Chlorpheneramine maleate Allergies:
To foods (list):
To medications: (list):
Lice shampoo or scabies cream (Nix or Elimite) To the environment (insect stings, hay fever, etc.– list):
Other allergies: (list):
Describe previous reactions:
Diet, Nutrition: Eats a regular diet. Has a medically prescribed meal plan or dietary restrictions:(describe below)
The camper is undergoing treatment at this time for the following conditions: (describe below) None.
Medication:
No daily medications. Will take the following prescribed medication(s) while at camp: (name, dose, frequency—describe below)
Other treatments/therapies to be continued at camp: (describe below) None needed.
Do you feel that the camper will require limitations or restrictions to activity while at camp? No Yes

If you answered “Yes” to the question above, what do you recommend? (describe below—attach additional information if needed)

“I have reviewed the CAMPER HEALTH HISTORY FORM (FORM 1), and have discussed the camp program with the camper’s
parent(s)/guardian(s). It is my opinion that the camper is physically and emotionally fit to participate in an active camp program (except as
noted above.)
Name of licensed provider (please print): __________________________________Signature: _________________________________Title: _________ Office Address_____________________________________________________________________________________________________________ Telephone: (________)_____________________ Copyright 2008 by American Camping Association, Inc.

Source: http://www.zootopia.org/ZootopiaRegistrationForm.pdf