KENT-EVERGREEN DAY CAMP 2023
LOCATION
OUR WEBSITE HAS MOVED
kedcgsww.wixsite.com/kent-evergreen-day-c
KENT-EVERGREEN DAY CAMP 2022
ONLINE REGISTRATION FORM
--> Camper ~ 1st-6th Grades
--> Preschool Unit
--> Boy Unit
Email:
[email protected]
Camp Physical Location: 21230 SE 184th St, Maple Valley, WA 98038
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Indicates required field
Camper Name
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First
Last
Camper T-Shirt Size
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Choose One
Y S
Y M
Y L
Y XL
A S
A M
Camper First Year?
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Choose One
Yes
No
Camper Age in July (number format)
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Camper Grade in Fall
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Choose One
Preschool
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
Camper Special Needs (any allergies, etc. we should know about)
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Camper DOB (mm/dd/yyyy)
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Girl Scout Membership?
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Choose
Yes camper is a registered Girl Scout
No camper is not currently a registered Girl Scout
Troop #
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Service Unit #
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Paying with Cookie Card? List the dollar amount for reimbursement and all three numbers on back of the card
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Parent/Guardian Name
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First
Last
1st Contact
Parent/Guardian Mailing Address
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Line 1
Line 2
City
State
Zip Code
Country
P/G Home #
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P/G Work #
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P/G Cell #
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Parent/Guardian E-Mail
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Parent/Guardian Name
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First
Last
2nd Contact
Parent/Guardian E-Mail
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P/G Home #
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P/G Cell #
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P/G Work #
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Emergency Contact Name 1
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First
Last
Relative, Neighbor, Care Provider, etc.
Emergency Contact #
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Emergency Contact Relationship
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Emergency Contact Name 2
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First
Last
Relative, Neighbor, Care Provider, etc.
Emergency Contact #
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Emergency Contact Relationship
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Have additional Information for us? Let us know below.
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THE NEXT SECTION IS YOUR CAMPER'S HEALTH INFORMATION.
If your camper will require medication at camp, complete the
Medical Provider Permission for Medication form
and the
Parental Permission for Medication form
** Volunteers cannot administer MEDICATIONS WITHOUT PARENT/DOCTOR PERMISSION**
Doctor's Name
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Phone Number
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PART 1: ILLNESS & INJURIES *
Illness & Injuries (History of)
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Ear Infection
Bleeding/Clotting Disorder
Hypertension
Asthma
Heart Defect/Disease
Musculoskeletal Disorders
Seizures
Diabetes
None of the above
Date of Last Health Exam (mm/dd/yyyy)
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Is the participant under a doctor's/psychologist's care now?
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Yes
No
Were any complicating medical problems noted in the last health exam?
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Yes
No
Since the last health exam, has the participant had ...
Serious injury requiring medical attention?
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Yes
No
Any prescribed or over the counter medications?
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Yes
No
Treatment in a hospital or emergency room?
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Yes
No
Any illness lasting more than 5 days?
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Yes
No
A surgical procedure or fracture?
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Yes
No
Any exposure to a contagious disease?
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Yes
No
Any restrictions concerning physical activity?
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Yes
No
If you answered yes to any of the above questions, please explain, including dates.
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PART 2: ALLERGIES & OTHER HEALTH CONDITIONS
ALLERGIES
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Animals
Pollen
Medications/Drugs
Plants
Hay Fever
Food
Insect Stings
Other
None
Specify nature of allergic reaction
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OTHER CONDITIONS
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Bedwetting
Constipation
Menstrual Cramps
Motion Sickness
Nosebleeds
Sleep Disturbances
Emotional Disturbances
Fainting
Hearing Impairment
Sickle Cell Trait or Disease
Special Diet Regime
Wear Glasses or Contact Lens
Other Condition? Please specify.
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PART 3. IMMUNIZATION HISTORY -
please list year primary series was completed or year of last booster
DPT: Diphtheria/Pertussis/Tetanus
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MUMPS
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TETANUS/DIPTHERIA BOOSTER
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RUBELLA (German Measles)
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MEASLES
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ORAL POLIO
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OTHER
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I know of no other reason(s), other than the information indicated on this form, why my daughter should not participate in prescribed activities except as noted
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Yes
No
By typing my name in the box below I am agreeing to the above statement.
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CONSENT OF PARENT/GUARDIAN
P
lease read all paragraphs below before clicking on the SUBMIT button
As parent/guardian having legal custody of the camper named above, who is voluntarily enrolled as a participant in the Girl Scouts of Western Washington Community Day/Twilight Camp Program, I agree to instruct my child to observe rules and regulations governing the activities.
I understand camping programs involve inherent risk and possible injury because of the nature of the activity, even when conducted in a safe manner.
I give permission for her to attend camp and participate in all phases of the program including off-site activities and related transportation.
I understand her good health is required before she can attend camp.
As the parent/guardian of the above child, I give permission for the above child to be photographed and/or audio/video taped during this event and for the images/recordings to be published, reproduced, or distributed by Girl Scouts and its affiliates in all outlets, including but not limited to television, newspapers, internet, council publications, recruitment materials and ads without liability or limitation or claims on my or my minor’s part.
I give my permission for my daughter/ward to join Girl Scouts, if she is not currently registered I need to
click here to register for Girl Scout membership valid through September 30, 202
3
. P
lus, for this year only, GSUSA has decided to offer Extended Year Membership to any new or past members. Meaning your friends and family can join or re-join Girl Scouts now and continue through September 2023 for only $35!
I have read the
GSWW COVID Policy
and K
EDC COVID Policy
.
COVID-19 Participation Acknowledgment:
Girl Scouts of Western Washington (GSWW) is committed to taking precautions to mitigate risk as well as to follow applicable federal, WA State, local and GSUSA COVID-19 directives and guidelines. Our council is also committed to having in-person activities as allowed and in accordance with those mandates. GSWW’s operations and programs occurring while COVID-19 is circulating in our community may expose our members, volunteers, and employees to the risk of infection. GSWW cannot prevent you from becoming exposed to, contracting or spreading COVID-19 while attending (which includes being present in any capacity) any GSWW in-person programming. Therefore, any interaction with others in connection with in-person programming may expose you and your family to, and increase your risk of contracting or spreading, COVID-19.
On behalf of myself, I agree to the following:
1.
I understand
Novel Coronavirus (‘‘COVID-19”) infections have been confirmed throughout the United States, including multiple cases in my area.
2.
I understand
COVID-19 is an extremely contagious virus that spreads easily, including through person-to-person contact.
3. I understand, as with any social activity, use of Girl Scouts of Western Washington (GSWW) facilities or services, or participation in GSWW programs, may present the risk of contracting COVID-19. I further understand GSWW takes safety and preventative precautions, and that GSWW can in no way warrant that COVID-19 infection will not occur through use of such facilities or services or participation in GSWW activities, in-person troop meetings and/or programs.
4.
I understand
the known and potential dangers of participating in the programs and/or utilizing the facilities and services of GSWW and acknowledge that my use thereof, and/or use by my participating children may, despite GSWW’s prudent and reasonable efforts to mitigate such dangers, result in exposure to COVID-19, which could result in quarantine requirements, serious illness, disability, and/or death.
5.
I understand
that due to the nature of the facilities, services, and programs offered by GSWW, social distancing of 6 feet per person among children and/or others, and compliance with guidance and recommendations of public health agencies, may not always be possible.
6.
I understand
that GSWW may revise its procedures at any time based on updated recommended guidance and recommendations issued by public health agencies and other authorities, and that I and my participating children must comply with all GSWW procedures prior to participating in, visiting, or utilizing the facilities, services, and/or the programs and/or attending in-person troop meetings or in-person service unit meetings of GSWW.
GSWW has put in place preventative health and safety measures to reduce the spread of COVID-19; however, GSWW cannot guarantee that you will not become infected with COVID-19 should you choose to participate in in-person programming. Participants who do not agree to these statements should not join in-person GSWW activities.
By signing below,
I attest that I have read the Girl Scouts of Western Washington's COVID-19 Member Guidelines, updated Safety Activity Checkpoints, Volunteer Essentials and Volunteer Policies. I agree to abide by and stay informed of GSWW’s policy guidelines as a condition of my volunteer and participant role with Girl Scouts of Western Washington.
I HAVE CAREFULLY READ AND VOLUNTARILY SIGN THIS ASSUMPTION OF RISK, RELEASE AND WAIVER OF LIABILITY RELATING TO CORONAVIRUS/COVID-19 AND FURTHER AGREE THAT NO ORAL REPRESENTATIONS, STATEMENTS, OR INDUCEMENT APART FROM THE FOREGOING WRITTEN AGREEMENT HAVE BEEN MADE.
THIS DOCUMENT IS A PROMISE NOT TO SUE AND A RELEASE OF ALL CLAIMS. I AM AWARE THAT BY SIGNING THIS AGREEMENT I AM GIVING UP VALUABLE LEGAL RIGHTS, INCLUDING THE RIGHT TO RECOVER DAMAGES FROM GSWW IN CASE OF ILLNESS, INJURY, DEATH OR PROPERTY LOSS OR DAMAGE, INCLUDING, FOR THE AVOIDANCE OF DOUBT AND WITHOUT LIMITATION, EXPOSURE TO COVID-19 AT ANY GSWW FACILITY OR DURING PARTICIPATION IN ANY PROGRAM OR ACTIVITY OR TRAVEL RELATED THERETO AND ANY ILLNESS, INJURY OR DEATH RESULTING THEREFROM.
I am able to view a copy of these documents on the GSWW website and/or the resources section of this course. I understand that if I have questions, at any time, regarding any of the policies and procedures, I will contact the Girl Scouts of Western Washington Customer Care Team at (800) 541-9852 /
[email protected]
By typing my name in the box below I am agreeing to the above statement.
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SUBMIT