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.

Yes

No Photos

Name of Camper *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Camp *

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. The pool is divided into two identified sections, the shallow end ranges from 3- 5 feet deep and the deep end ranges from 5-10 feet deep. Lifeguards are on duty while children are using the pool, however, we highly recommend that children who are not proficient in swimming use the shallow end. Please note that we have a limited number of life jackets for younger children. It is preferred that children bring their own life jacket, labeled with their name should they require one.

Life jacket in shallow and deep end of pool

Life jacket in the deep end only

Good swimmer, no life jacket

We will provide a life jacket

Is Tetanus Shot Current? *

YES

NO

Date of Last Known Tetanus

MM

DD

YYYY

Name of Camper #2 *

First Name

Last Name

Birthdate of Camper #2 *

MM

DD

YYYY

Camp *

Summer Blast ages 6-8

All Day Camp 9-11

All Day Camp 12-14

Swim Ability

Pool safety is important to us. The pool is divided into two identified sections, the shallow end ranges from 3- 5 feet deep and the deep end ranges from 5-10 feet deep. Lifeguards are on duty while children are using the pool, however, we highly recommend that children who are not proficient in swimming use the shallow end. Please note that we have a limited number of life jackets for younger children. It is preferred that children bring their own life jacket, labeled with their name should they require one.

Needs Life Jacket in shallow and deep end

Needs life jacket only in the deep End

Good Swimmer

We will provide life jacket

Is Tetanus Current? *

Yes

No

Date of Last Tetanus

MM

DD

YYYY

Name of Camper #3

First Name

Last Name

Date of Birth

MM

DD

YYYY

Camp *

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. The pool is divided into two identified sections, the shallow end ranges from 3- 5 feet deep and the deep end ranges from 5-10 feet deep. Lifeguards are on duty while children are using the pool, however, we highly recommend that children who are not proficient in swimming use the shallow end. Please note that we have a limited number of life jackets for younger children. It is preferred that children bring their own life jacket, labeled with their name should they require one.

Life jacket in shallow and deep end

Life jacket in the deep end only

Good swimmer

Will provide our Own lifejacket

Is Tetanus Current?

Yes

No

Date of Last Tetanus

MM

DD

YYYY