Eastern Yacht Club - Junior Activities Instructors Info Form

GROUPING POLICY Children are organized strictly by their birthdate into four groups: Clippers (7-8 yrs), Schooners (6-7 yrs), Sloops (5-6 yrs) and Prams (4-5 yrs). We cannot take requests for group placement. Final participant lists will be emailed out in June. There are no exceptions to this rule.
Grouping Policy: *	(you must check here to indicate you agree to this policy stated above)
Child's Information
Child's First Name: *
Child's Last Name: *
Birth Date: *	(mm/dd/yyyy)
Age: *	(please enter age on the first day of camp)
Gender: *
T-Shirt Size: *
Parent's Information
Mother's Name: *
Mother's Mailing Address: *
Mother's City: *
Mother's State: *
Mother's Zip Code: *
Father's Name: *
Father's Mailing Address: *
Father's City: *
Father's State: *
Father's Zip Code: *
EYC Member #: *
Primary Daily Email Address: *
Phone & Contact Information
Mother's Home Phone: *
Mother's Cell Phone: *
Mother's Work Phone:
Father's Home Phone: *
Father's Cell Phone: *
Father's Work Phone:
Child's Home Phone: *
Emergency Contact and Medical Information for a Child Alternative Emergency Contacts In the event of an emergency when I may not be reached, the EYC Junior Activity head counselor or EYC General manager may contact the following individuals (in the order given) whom I authorize to take my child from The Eastern Yacht Club Camp and facility.
Primary Emergency Contact Name: *
Primary Emergency Contact's Relationship: *
Primary Emergency Contact's Address: *
Primary Emergency Contact's City: *
Primary Emergency Contact's State: *
Primary Emergency Contact's Zip Code: *
Primary Emergency Contact's Home Phone: *
Primary Emergency Contact's Cell Phone: *
Primary Emergency Contact's Work Phone: *
Secondary Emergency Contact Name: *
Secondary Emergency Contact's Relationship: *
Secondary Emergency Contact's Address: *
Secondary Emergency Contact's City: *
Secondary Emergency Contact's State: *
Secondary Emergency Contact's Zip Code: *
Secondary Emergency Contact's Home Phone: *
Secondary Emergency Contact's Cell Phone: *
Secondary Emergency Contact's Work Phone: *
Medical Information
Physician's Name: *
Physician's Phone: *
Health Insurance Provider & Group #: *	(please provide group or policy number)
Allergies/Special Health Considerations: *
I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency. I give permission for my child to go on field trips. I release [Organization] and individuals from liability in case of accident during activities related to [Organization], as long as normal safety procedures have been taken.
Initials - Medical: *	(initial here to agree to the Emergency Contact and Medical Information for a Child Form)
Authorized Person(s) To Pick Up Child I additionally authorize the following individual to take my child from the Eastern Yacht Club Junior Activities program. NOTE: If your child or children will be picked-up on a regular basis by someone other than yourself please list their name and contact information below. NOTE: It is advised that you notify the camp at the beginning of the day when your child will be picked up by one of the authorized individuals.
Alternate Authorized Pick-Up Contact Name:
Alternate Authorized Pick-Up Contact Address:
Alternate Authorized Pick-Up Contact City:
Alternate Authorized Pick-Up Contact State:
Alternate Authorized Pick-Up Contact Zip Code:
Alternate Authorized Pick-Up Contact Home Phone:
Alternate Authorized Pick-Up Contact Cell Phone:
Initials: *	(initial here if you filled out an alternate pick-up contact and if you agree to the Authorized Pick-Up Contact Form above)
Authorization to Administer Medication to a Camper
Does your child have medications you authorize us to administer?: *	(if yes, please complete the remainder of this section below
Food/Drug Allergies:
Diagnosis:	(at parents discretion)
Name of Licensed Prescriber:
Name of Medication:
Dose Given At Camp:
Route of Administration:
Frequency:
Date Ordered:
Duration of Order:
Quantity Received:
Expiration Date of Medications Received:
Special Storage Requirements:
Specific Directions:
Specific Precautions:
Possible Side Effects/Adverse Reactions:
Other Medications:	(at parents discretion)
Location Where Medication Administration Will Occur:
Authorization to Administer Medication to a Camper I hereby authorize the EYC Junior Activities Program to administer, to my child listed above the medication(s) listed above, in accordance with 105 CMR 430.160. 105 CMR 430.160(A) Medication prescribed for campers shall be kept in original containers bearing the pharmacy label, which shows the date of filling, the pharmacy name and address, the filling pharmacist"�s initials, the serial number of the prescription, the name of the patient, the name of the prescribing practitioner, the name of the prescribed medication, directions for use and cautionary statements, if any, contained in such prescription or required by law, and if tablets or capsules, the number in the container. All over the counter medications for campers shall be kept in the original containers containing the original label, which shall include the directions for use. 105 CMR 430.160(C) Medication shall only be administered by the health supervisor* or by a licensed health care professional authorized to administer prescription medications. The health care consultant shall acknowledge in writing the list of medications administered at the camp. If the health supervisor is not a licensed health care professional authorized to administer prescription medications, the administration of medications shall be under the professional oversight of the health care consultant. Medication prescribed for campers brought from home shall only be administered if it is from the original container, and there is written permission from the parent/guardian. 105 CMR 430.160(D) When no longer needed, medications shall be returned to a parent of guardian whenever possible. If the medication cannot be returned, it shall be destroyed. *Health Supervisor "� A person who is at least 18 years of age, specially trained and certified in at least current American Red Cross First Aid (or its equivalent) and CPR, has been trained in the administration of medications and is under the professional oversight of a licensed health care professional authorized to administer prescription medications.
Initials - Medication: *	(initial here to agree to the Authorization to Administer Medication to a Camper Agreement above)
On-the-Water Activities for Junior Activities Camp Acknowledgement and Release Form The undersigned acknowledges and understands the following (NOTE: where the program participant is a child under the age of 18, the undersigned must be a parent or other legal guardian): 1. The Eastern Yacht Club program participants, parents and legal guardians have been given the opportunity, at scheduled meetings and otherwise, to ask questions and discuss with EYC staff the safety and recreational aspects of EYC on-the-water programs and activities prior to their commencement. 2. The EYC has made reasonable and prudent efforts to safeguard the health and well-being of participants in EYC on-the-water programs and activities through safety policies and staff supervision of activities, among other measures. Such policies include, without limitation, (A) a strict policy regarding the required use of personal floatation devices by all program participants under the age of 16 during program activities; and (B) the administration of a swimming test appropriate to the activities of the program and its participants. 3. No safety measures, including those described above, can guarantee the safety of any participant in EYC on-the-water programs and activities. Accordingly, the undersigned hereby releases the EYC, its employees, volunteer staff, agents and members from, and waives any and all claims, losses or liabilities resulting from or related to, the above-named person"�s participation in on-the-water programs and activities of the EYC.
Initials - Release: *	(initial here to agree to the On-the-Water Activites Acknowledgement & Release Agreement above)
Immunization Forms The Marblehead Board of Health requires that we have on file necessary information for your child on hand and in order for your child to attend Camp this summer. We must have a hard copy of you child's/children's medical history and immunizations forms (not unlike required to attend school) sent directly to Kerry Zurn, 16 Wyman Road, Marblehead, MA 01945. The deadline for this is May 1, 2012.
Immunization Forms: *	(Check here to acknowledge that you will provide this information before the May 1, 2012 deadline.)
Health History Form: *	(Check here to acknowledge that you will submit this separate Health History form via the website before the May 2, 2012 deadline. *NOTE* You will be presented with this form on the last page of the online registration process.)

	* indicates required information