Athletic Summer Camp Health Registration

Health Registration for Athletic Summer Camps

The Woodstock Academy Health Office
Complete this form after you have registered for an athletic summer camp.
Camper Information
Name*

First NameLast Name
Select the camp(s) your student is registered for:*

Basketball - Centaur Summer Camp - August 4-8Baseball - Centaur Summer Camp - August 4-8Basketball - Centaur Summer Camp - August 11-15Baseball - Centaur Summer Camp - August 11-15
Date of Birth*

MonthDayYear
Date
Contact Information
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Primary Phone Number*

Area CodePhone Number
Parent/Guardian Secondary Phone Number*

Area CodePhone Number
Alternate Emergency Contact*

First NameLast Name
Alternate Emergency Contact Primary Phone Number*

Area CodePhone Number
Alternate Emergency Contact Secondary Phone Number

Area CodePhone Number
Medical Information

and Emergency Consent
Does your child have allergies?*

yesno
Does your child have a bee sting allergy?*

yesno
Does your child have asthma or use an inhaler?*

yesno
Does your child have any health concerns that will require a consult with a nurse?*

yesno
Does your child need medications while at camp?*

yesno
If yes to any of the above, please explain:
Is there any additional health or medical information that we should be aware of?
Medical Insurance Company*
Insurance ID Number*
Insurance Phone Number*

Area CodePhone Number
Guarantor Name (person carrying insurance)*

First NameLast Name
Guarantor's Employer*
Guarantor's Date of Birth*

MonthDayYear
Date
Upload a copies or pictures of insurance card*

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Family Medical Doctor*
Family Medical Doctor Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Medical Doctor's Phone Number*

Area CodePhone Number
Family Dentist*
Family Dentist Phone Number*

Area CodePhone Number
Additional Forms

Physical Examination form & Authorization for the Administration of Medication by School, Child Care, and Youth Camp Personnel form
Physical Examination Form

In order to participate, all campers must have proof of a physical that has been completed within 13 months of the end date of the camp. You may use the form on The Woodstock Academy Camps page or a form provided by your physician. The form can be attached here or emailed to bsaucier@woodstockacademy.org before the beginning of the camp. Campers will NOT be able to participate without this form.
Upload Physical Examination Form

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Authorization to administer medication

If the camper will need medication administered during camp hours, please complete the Authorization for the Administration of Medication by School, Child Care, and Youth Camp Personnel form.

Download the form on our Centaur Summer Camps page. The form can be attached here or emailed to bsaucier@woodstockacademy.org before the beginning of the camp.
Upload Authorization to Administer Medication form

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Only if your camper requires medication to be administered at camp. Cancelof
Emergency Medical Consent:

I affirm that the information above is complete and that my son/daughter is in good health to participate in The Woodstock Academy Summer Academic Camps. I understand that it is the parent’s responsibility to notify the Nurse/Camp Director of any health concerns or needs of my child during the camp. In addition, by signing below I give permission for The Woodstock Academy medical staff to treat my child and/or transport to the nearest medical facility if an emergency arises and the emergency contact is not able to be reached.
Name*

First NameLast Name
Signature*

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Should be Empty:

Health Registration for Athletic Summer Camps

Camper Information

Contact Information

Medical Information

Additional Forms