One step closer to BIG DREAMS!  


DIRECTIONS:  Summer camp registration is a 2-part process.  You are now ready to complete PART II.  Please provide responses to all REQUIRED and RELEVANT fields.  Upon submitting this form you will receive an email notifying you that you have FULLY completed the Ebersole summer camp registration process.  Should you have any questions or concerns about the summer camp registration process please do not hesitate to contact us at 517-755-5000.

 

With gratitude and appreciation, Ben Botwinski (Ebersole Director)

 

  Ebersole Summer Camp Registration - Part II


PART II - SECTION A: CAMPER'S INFORMATION
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PART II - SECTION B: CAMPER'S EMERGENCY CONTACTS
Special Note: We will assume that the PRIMARY Emergency Contact is the parent/guardian listed in PART I of the registration.
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PART II - SECTION C: CAMPER'S PRIMARY MEDICAL CARE & MEDICAL INSURANCE
Help for If YES, please provide the name of the SUBSCRIBER for the medical insurance policy: The SUBSCRIBER is the individual who's name the medical insurance is under. This is usually the person who's name is on the medical insurance card.
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SECTION D: CAMPER'S IMMUNIZATIONS
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SECTION E: CAMPER'S ALLERGIES
If YES, name the item(s) that this camper is allergic to and indicate the reaction.
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SECTION F: CAMPER'S ASTHMA
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PART II - SECTION G: CAMPER'S DIET & SLEEPING HABITS
Select all that apply to this camper's diet.
Select all that apply to this camper's sleeping habits.
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PART II - SECTION H: CAMPER'S CHALLENGES
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PART II - SECTION I: CAMPER'S MEDICATIONS
Special Note: A Health Officer is staffed on-site at the Ebersole Center 24 hours a day when campers are present. The Health Officer is responsible for distributing all medications to campers.
Special Note: All medication listed on this form must come with the camper. All prescriptions - including inhalers and EPI-Pens – MUST be in the original box or bottle showing the campers name, what time the medication is taken, and the dose.
Special Note: Medication is any substance a person takes to maintain and/or improve their health. This includes vitamins and natural remedies. Please provide enough of each medication to last the entire time the camper will be at camp. Expired prescriptions will not be dispensed.
Camper's Medications:  (required)
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PART II - SECTION J: CAMPER'S PHOTO RELEASE
The Lansing School District occasionally use photographs and/or video of campers for promotional purposes through broadcast, print, or social media. Please review the options and select one that best describes your wishes in regards to CAMP photo and video usage.  (required)
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PART II - SECTION K: PARENT/GUARDIAN'S ACKNOWLEDGEMENTS
Special Note: If there is a religious objection to consenting to receipt of emergency medical or surgical treatment, the authorized person shall submit a written statement to the effect that the camper is in good health and that the person signing assumes the health responsibility for the camper.
Special Note: State of Michigan licensing rule 400.11127(2) states that a camp shall maintain, in the camp, a health history statement signed by an authorized person for each camper and minor staff person.