Please select the program(s) you, or the student you are registering, are interested in attending:
(required)
October 6-8, 2023. Kickstart Weekend.
November 3-5, 2023. Kickstart Weekend.
December 1-3, 2023. Kickstart Weekend.
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PART I: STUDENT'S INFORMATION
Student's Last Name:
Student's First Name:
Student's Date of Birth (MM/DD/YYYY):
Student's ID #:
Student's Gender:
(Please Select)
Male
Female
Other
Prefer Not to Say
Student's School (for 2022-23):
(Please Select)
Attwood
Averill
Beekman
CAK12O
Cavanaugh
Cumberland
Dwight Rich
Eastern
Everett
Forest View
Gardner
Gier Park
Kendon
Lansing Learning Hub
Lewton
Lyons
Mt. Hope
North
Pattengill
Post Oak
Reo
Riddle
Sexton
Sheridan Rd.
Wexford
Willow
Woodcreek
Other
Student's Grade Level (for 2022-23):
(Please Select)
Pre-Kindergarten
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
Parent/Guardian's Last Name:
Parent/Guardian's First Name:
Parent/Guardian's Primary Phone:
Parent/Guardian's Email Address:
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PART II: STUDENT'S EMERGENCY CONTACTS
Special Note: We will assume that the PRIMARY Emergency Contact is the parent/guardian listed above.
(Secondary) Emergency Contact's Last Name:
(Secondary) Emergency Contact's First Name:
(Secondary) Emergency Contact's Relationship to the Student:
(Please Select)
Parent
Grandparent
Aunt/Uncle
Family Friend
Other
(Secondary) Emergency Contact's Phone:
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PART III: STUDENT'S PRIMARY MEDICAL CARE & MEDICAL INSURANCE
Does this student have a primary care doctor?
(Please Select)
Yes
No
If YES, please provide the name of this student's primary care doctor:
If YES, please provide the phone number of this student's primary care doctor:
Is this student covered by medical insurance?
(Please Select)
YES
NO
If YES, please provide the name of the medical insurance company:
If YES, please provide the phone number for the medical insurance company:
If YES, please provide the relevant medical insurance policy number:
If YES, please provide the name of the SUBSCRIBER for the medical insurance policy:
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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PART IV: STUDENT'S IMMUNIZATIONS
Are all of the student's immunizations up to date?
(Please Select)
YES
NO
If NO, please initial the box below acknowledging that you understand and accept the risks to your student from not being fully immunized.
Please provide the month and year of the student's last tetanus immunization (MM/YYYY):
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PART V: STUDENT'S ALLERGIES
Is this student allergic to any food, medication, or insect stings?
(Please Select)
YES
NO
If YES, name the item(s) that this student is allergic to and indicate the reaction.
Item #1: My student is allergic to:
My student's reaction to Item #1 is:
(Please Select)
Intolerance
Anaphylaxis (requires an EPI-Pen)
Item #2: My student is allergic to:
My student's reaction to Item #2 is:
(Please Select)
Intolerance
Anaphylaxis (requires an EPI-Pen)
Other allergy related information about the student that we may need to know about:
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PART VI: STUDENT'S ASTHMA
Does this student have medically-diagnosed asthma that requires you to send an inhaler to camp?
(Please Select)
YES
NO
If YES, does the student need staff help to use their rescue inhaler?
(Please Select)
YES
NO
If YES, what triggers the student's asthma?
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PART VII: STUDENT'S DIET & SLEEPING HABITS
Select all that apply to this student's diet.
This student eats a vegetarian diet.
This student has a lactose intolerance.
This student has a gluten intolerance.
Any other dietary information about this student that we should know about:
Select all that apply to this student's sleeping habits.
This student is prone to sleep walking.
This student is prone to bedwetting.
This student is prone to rolling out of bed.
Any other sleep-related information about this student that we should know about:
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PART VIII: STUDENT'S CHALLENGES
Please share any information about physical difficulties you think are important for us to know about or that may impact this student's ability to fully participate in camp activities:
Please share any information about mental, emotional, or social difficulties you think are important for us to know about or that may impact this student's ability to fully participate in camp activities:
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PART IX: STUDENT'S MEDICATIONS
Special Note: A Health Officer is staffed on-site at the Ebersole Center 24 hours a day when students are present. The Health Officer is responsible for distributing all medications to students.
Special Note: All medication listed on this form must come with the student. All prescriptions - including inhalers and EPI-Pens – MUST be in the original box or bottle showing the student's 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 student will be at camp. Expired prescriptions will not be dispensed.
Student's Medications:
(required)
NO, this student will not take any daily medications while at camp.
YES, this student will bring an inhaler or EPI-Pen to camp.
YES, this student will take the following daily medications while at camp.
Name of Medication #1:
Medication #1 - Amount or Dosage:
Medication #1 - Reason for Taking:
Medication #1 - Given at:
(Please Select)
Breakfast
Lunch
Dinner
Bedtime
Other
Name of Medication #2:
Medication #2 - Amount or Dosage
Medication #2 - Reason for Taking:
Medication #2 - Given at:
(Please Select)
Breakfast
Lunch
Dinner
Bedtime
Other
Name of Medication #3:
Medication #3 - Amount or Dosage
Medication #3 - Reason for Taking:
Medication #3 - Given at:
(Please Select)
Breakfast
Lunch
Dinner
Bedtime
Other
Please provide any additional medication related information about this student that you think we should know about:
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PART X: STUDENT'S PHOTO RELEASE
The Lansing School District occasionally use photographs and/or video of students 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)
YES, it is alright for the Lansing School District to use CAMP photos and/or video of my student for promotional purposes through broadcast, print, and/or social media.
NO, it is not alright for the Lansing School District to use CAMP photos and/or video of my student for promotional purposes through broadcast, print, and/or social media.
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PART XI: PARENT/GUARDIAN'S ACKNOWLEDGEMENTS
(A) Please initial to acknowledge that the information contained in this form is correct and accurately reflects the health status of the student to whom it pertains.
(B) Please initial to acknowledge that this student has permission to participate in all camp activities.
(C) Please initial to acknowledge that you understand the information on this form will be shared on a “need to know” basis with camp staff, and that you give permission to photocopy this form.
(D) Please initial to acknowledge that you understand that if your student needs to be sent home due to illness, injury, or disciplinary reasons, that you are responsible for picking your student up.
(E) Please initial to acknowledge that you understand that the camp has limited health care onsite and that staff will call the indicated parent/guardian in an emergency and/or if your student is unable to continue because of injury or illness.
(F) Please initial to acknowledge that you give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of your student in emergency situations.
(G) Please initial to acknowledge that if you cannot be reached in an emergency, you give your permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this student.
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 student is in good health and that the person signing assumes the health responsibility for the student.
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 student and minor staff person.
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