Health Form

Parent or Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Second Parent or Guardian *

First Name

Last Name

Phone of Second Parent or Guardian *

(###)

###

####

Emergency Contact *

If Parents or Guardian Cannot be Reached

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Photography Release *

If your child is in a photograph taken by Jump-In NW designated staff the photograph may be used in publications on-line or in print for advertising purposes. Jump-In NW will not include the name of our campers on any publications or sell merchandise with your child's/children's photo. Jump-In NW will not share your child's/children photo with any business. It is for the exclusive use of Jump-In NW Camp publications and advertising. If you choose not to have your child allowed in publications they will not be in group photos when taken and will have a red circle on their tag so the photographer knows not to take photos of that child.

Yes

No Photos

Name of Camper *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Camp Registered *

Check All That Apply

Summer Blast Ages 6-8

All Day Camp Ages 9-11

All Day Camp Ages 12-14

Swim Ability

Pool Safety is important to us. Please let us know your childs ability to navigate a pool that goes from 3ft to 10ft deep. Life Guards are on duty for all of our swim sessions. We have a limited amount of life jackets available for young kids. If you can bring your childs life jacket each day it is helpful. Please make sure to label the jacket with your childs name.

Life Jacket in the Pool

Life Jacket in the Deep end Only

Will Bring a Life Jacket

Good Swimmer

Is Tetanus Shot Current? *

YES

NO

Date of Last Known Tetanus

MM

DD

YYYY