Camp St. Vincent Intake Form

Camper Details

First Name

Last Name

Camper Birthdate

Gender

Race

Ethnicity

Alumni Status

Shelter of Residence

Select all the weeks of camp your child will be unable to attend. (select all that apply)

Photo consent

School Details

Name of School Attended in 2021 - 2022

Current Grade Enrolled as of June 2022

Baltimore City School ID (optional)

Health

Please enter N/A if there is no response.

Food Allergies

Medication Allergies

Other Allergies

Have Asthma?

Any additional health problems?

Description of Health Problems

Child currently taking medication? If yes, please provide details below.

Please include dosage, medication times, and any additional information.

Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Adult Contact Details

Parent/Guardian Name

Home # of Parent/Guardian

Work # of Parent/Guardian

Cell # of Parent/Guardian

Emergency Contact Name

Emergency Contact Home #

Emergency Contact Cell #

Transportation Details

Person with permission to pick child up

Transportation Phone #

Each applicant is required to complete parent/guardian and opt-in online consent form(s). Please proceed to the next page to complete.

PARENT/GUARDIAN CONSENT AGREEMENT

Please provide your response for each statement below for consent/agreement:

The health history provided is correct so far as I know, and the participating child has permission to engage in all prescribed program activities. I hereby give permission to medical personnel to administer first aid.

I hereby authorize the SVDP Program to have and use photographs and video of the child named on this application as may be needed for its records or public relations purposes. I understand the child named on this application may have his/her picture taken for publication in the local newspaper and video clips may be used for the local news.

During the course of the summer, children may be exposed to excessive sunlight. I hereby give permission for program personnel to apply sunscreen lotion (cream or spray) to the skin of my child prior to exposure to sunlight. If NO, please ensure any allergies or sensitivities have been identified on the first page of this application.

I understand that if my child misses 3 days without prior notification (via in writing or phone call to the program office) the child will be unenrolled for any upcoming sessions.

I hereby give permission to the medical personnel selected by the SVDP program director to order x-rays, routine tests, treatment to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the program director to secure and administer treatment, including hospitalization of the person named on the application.

Please complete the OPT-IN/OUT Form below.

Upon completion of the OPT-IN Summer Funding Collaborative Form, please click SUBMIT at the bottom of this page or your application WILL NOT be sent!

ONLINE CONSENT FORM [ENGLISH]

ONLINE CONSENT FORM [SPANISH]