Agape Life Ministries, Inc.

AGAPE LIFE STEM SUMMER & AFTER-SCHOOL CAMP PROGRAM APPLICATION FORM

8568 Laureldale Dr,
Laurel, MD 20724
Phone:
Office:(301)-725-6525
Cell: (301)-828-6664

Contact

✕

First Name

Last Name

Email

Phone (Cell)

Date of birth

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Gender

Add another person

AGAPE LIFE
STEM AFTER-SCHOOL PROGRAM
STEM SUMMER CAMP PROGRAM

Home Phone:

Work Phone:

Emergency Contact Info (Contact Name):

Phone Number

Relationship to child:

Grade:

Ethnicity:
African American
African
Asian
Native American
Caucasian
Other

Allergies
Yes
Choice Three

If YES Please List

Parent:
My child(ren) walks home
My child(ren) are picked up
My child takes public transportation

Authorized persons to pick up my child(ren) are : First & Last Name(s)

Phone Number(s)

If under 18 years of age please notify staff. My signature authorizes my child to be picked up only by the persons I have listed on this form unless otherwise notified in writing.

AGAPE LIFE STEM SUMMER CAMP PROGRAM HEALTH RECORD FORM

The health form is kept confidential and used by our Health Administrator, Trained Staff and/or Emergency Medical Personnel. Every camper needs a completed Health Record Form in order to participate in our summer camp programs in accordance to COMAR 10.16.07.08.

Please fill this out as completely as possible.
SECTION I — BASIC CONTACT INFORMATION

Camper Name - FIRST , LAST & MI

Date of Birth

Age

Gender
Male
Female

Home Address

Parent/Guardian #1 Name- FIRST , LAST & MI

Relationship:

Day Phone Number

Phone Number Type
Home Phone
Work Phone
Cell Phone

Additional Emergency Contact

(In case we can't reach YOU)

Family Physician Name - FIRST , LAST & MI

Contact Phone Number

Family Dentist/Orthodontist Name - FIRST , LAST & MI

Contact Number

SECTION II — INSURANCE INFORMATION
(In case we can't reach YOU)

Is the camper covered by family medical/hospital insurance?
Yes
No

If Yes, Indicate Insurance Carrier Group Number

Policy Number

Policy Holder Name

SECTION III - MEDICATIONS

Will camper be taking medications while at camp? (Medications include prescription, over-the-counter, vitamins, inhalers, etc.)
Yes
No

If camper will be taking medications while at camp, it is Maryland state law to secure your consent for medication distribution and for the use of medical devices. The medication can be self-administered (if over 18) or administered by Health Services Staff. Please list all (prescription and non-prescription) Include the medication name, prescribing physician, physicians' phone number, and the dosage instructions. Use an additional sheet if needed. When you check-in at camp, please provide all medications (in their original packaging that identifies the prescribing physician (if prescription drug), the name of the medication, the dosage, and frequency of administration.

Single Choice
I want the medication or medical devices self-administered. (Age 18 and above only.)
I want the medication or medical device administered by the Health Services Staff.

However, a limited amount of medication for life threatening conditions should be carried by my

Medication Dosage

Take at what times?

Reason for Taking

Prescribing Physician

Prescribing Physician Phone Number

SECTION IV - ALLERGIES

Camper does not have any Allergies
Yes
No

Camper is allergic to
Hay fever
Poison Ivy/Oak
Insect Stings
Food
Penicillin
Other Drugs

Other List allergy.

Describe reaction and treatment

SECTION V - IMMUNIZATIONS

Please record the month and year of immunizations. If you do not know the dates or whether camper has had certain immunizations, simply leave blank.

Multiple Choice
DPT (Diphtheria, Pertussis, Tetanus)
HIB (Haemophilus Influenza B)
Tetanus Booster Tuberculin Test
Polio Varicella (Chicken Pox)
MMR (Measles, Mumps, Rubella)
Hepatitis B

SECTION VI - HEALTH HISTORY

Please know that we value your privacy. Health History information is available only to the camp health staff. The more information you provide, the better we can do our job. Thanks!

Please list any other items not listed and provide an explanation for each

Date of Last Physical Exam (Recommended within 12 months of camp)

ATTACH A COPY OF CHILD'S IMMUNIZATION RECORD & PHYSICALS (WITHIN 12 MONTHS) FROM HEALTH CARE PROVIDER OR PRIMARY CARE PHYSICIAN

E-MAIL IT TO summercamp@agapelifeonline.org

Physical Activities to be Limited or Restricted while at Camp

My child has permission to engage in all prescribed camp activities except as noted. The information provided on this form is accurate to the best of my knowledge. I have indicated any special health conditions, including required medication and activity limitations which should be known to the camp staff and medical personnel. I am aware of and accept the risk inherent in the program activity. I give consent in advance for medical treatment at an appropriate facility in case of illness or injury.

Signature . By entering your initials in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.

Input Date

Signature of Parent or Guardian (If under 18 years old) By entering your initials in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.

Date

AGAPE LIFE STEM SUMMER & AFTER-SCHOOL CAMP PROGRAM APPLICATION FORM

AGAPE LIFE STEM SUMMER CAMP PROGRAM HEALTH RECORD FORM

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