* First Name :

* Last Name:

*Address:

*City:

*State:

*Zip Code:

*Phone:

*Cell Phone:

*Emergency Phone:

*Date of Birth:

*Gender:

If child does not go by his/her first name, what does he/she prefer to be called?:

* First Name :

* Last Name:

*Address:

*City:

*State:

*Zip Code:

*Home Phone:

*Work Phone:

*Relationship to Child:

* First Name :

* Last Name:

*Address:

*City:

*State:

*Zip Code:

*Home Phone:

*Work Phone:

*Relationship to Child:

* First Name :

* Last Name:

*Address:

*City:

*State:

*Zip Code:

*Home Phone:

*Work Phone:

*Relationship to Child:

* First Name :

* Last Name:

*Address:

*City:

*State:

*Zip Code:

*Home Phone:

*Work Phone:

*Relationship to Child:

*Diagnosis :

*Allergies (food, medication, bees, sun):

*Does your child take medication?

No Yes

*If yes, please state name, dosage, and the reason:

*Will the medication need to be given during camp hours? If yes, when?

*Please describe your child's mobility :

*Please describe your child's Hearing :

*Please describe your child's vision :

*Please describe your child's toileting :

*Any restrictions and / or limitiations?

No Yes

*If yes, please list:

*How does your child get along with other children?

*What works best when disciplining your child?

*Please give any further information, which you believe, will be helpful to staff in understanding and caring for your child :

*Tee Shirt size

Small Medium Large Extra Large

Camp will run from 9:00 A.M. to 3:00 P.M. Please Areive at those times to allow staff time for preperation.
Fee for camp is $50.00 a week.
The camp is located on the second floor of the YMCA building at 200 E. Jackson St. Elkhart IN

I, the undersigned Parent or Guardian of do hereby consent and grant permission for his/her participation at ADEC,Inc. Summer Camp. I agree to hold harmless ADEC,Inc. and or ADEC Summer Camp from any and all claims, damages or injuries which the above named child may suffer because of his/hers own independent act, acts of other campers, acts of nature, or actions taken by medical personnel whose services may be required to treat the camper. I hereby further give my consent for the camper to take part in all camp activities, including, but not restricted to athletic competition, field trips, nature studies, climbing activities and other traditional camp activities
(initials)
I understand that the child must comply with the camp rules and standards of behavior. I agree that ADEC Summer Camp has the right to enforce appropriate standard of conduct and that the organization may terminate the camper's participation in the camp program if he/she does not maintain these standards.
(initials)
I understand that the child cannot take any medication at the camp unless it is prescribed by a physician and is in the original pharmacy container. My son/daughter may be transported out of camp for program activities. I also give my permission for the child to receive medical treatment in case of injury or illness while in route to, from during camp. The camp has my permission to use photographs, video, or audio recordings of the child for public relations purposes.
(initials)
In signing this document, I certify that the child is healthy and free of problems that could adversely affect his/her stay or that of other children. If his/her care is more extensive than ADEC Summer Camp can realistically provide, I understand that they may have to shorten his/her camping experience.