STUDENT REGISTRATION AND HEALTH INFORMATION

Residential Overnight School Programs
at the Battle Creek Public Schools Outdoor Education Center, Clear Lake Camp
10160 S M-37 Hwy, Dowling, MI 49050. 269-721-8161. www.clearlakecamp.org

Name of Student Name of Student * First Last
*

MALE FEMALE
Date of Birth Date of Birth * / MM / DD YYYY
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Student's School *
Grade *
Teacher *
Student’s Parent/Guardian 1 *
Day Phone Day Phone * - ### - ### ####
Evening Phone Evening Phone * - ### - ### ####
Student’s Parent/Guardian 2
Day Phone Day Phone - ### - ### ####
Evening Phone Evening Phone - ### - ### ####
May we add you to our Friends of the OEC mailing list? *

May we add you to our Friends of the OEC mailing list? YES NO
Email Address
Emergency Contact #1 Emergency Contact #1 * First Last
Phone Number for Emergency Contact #1 Phone Number for Emergency Contact #1 * - ### - ### ####
Emergency Contact #2 Emergency Contact #2 First Last
Phone Number for Emergency Contact #2 Phone Number for Emergency Contact #2 - ### - ### ####
Name of Student’s Physician: Name of Student’s Physician: * First Last
Phone of Student’s Physician: Phone of Student’s Physician: * - ### - ### ####
MEDICATION AT CAMP
Any medication, prescription and over-the-counter, or supplement taken at camp
must come with a complete and accurate MEDICATION PERMISSION FORM signed by BOTH the student’s parent/guardian and the student’s physician.
Notwithstanding the preceding sentence, a physician’s signature is not required for a student to possess and use a United States Food and Drug Administration
approved, over-the-counter topical substance, as defined in MCL 380.1179. Review the MEDICATION INFORMATION SHEET for details.
Questions? Call the office at 269-721-8161.
PHOTO PERMISSION
I give permission for my child to be photographed and for their photo to be used on promotional media for the camp. No names shall be released and no compensation will be provided to the parent/guardian or student. *

PHOTO PERMISSION
I give permission for my child to be photographed and for their photo to be used on promotional media for the camp. No names shall be released and no compensation will be provided to the parent/guardian or student. YES NO
GENERAL HEALTH QUESTIONS
List any recent injury, illness, or infectious disease that may affect child’s participation
List any chronic/recurring illness or disease
List any special health and behavioral considerations, or physical limitations
List any ALLERGIES to foods, drugs, bee/wasp stings, etc.
List any FOOD RESTRICTIONS. i.e. Gluten free, Vegetarian, etc. Call ahead to Camp about any special diets! 269-721-8161
Does your child wet the bed? *

Does your child wet the bed? YES NO
Does your child Sleep Walk? *

Does your child Sleep Walk? YES NO
Are your child’s Immunizations up to date? *

Are your child’s Immunizations up to date? YES NO
Anything else we should know?
I give my permission for my child to attend the Battle Creek Public Schools (BCPS) Outdoor Education Center (OEC), a children's camp licensed by the State of Michigan, and participate in all planned activities. BCPS is not responsible for lost, stolen, or damaged personal articles. The answers to the above questions are correct to the best of my knowledge. I understand that in case of illness or accident an attempt will be made to contact me at the telephone number(s) listed above. In an emergency, if camp personnel are unable to contact me, I hereby give permission to BCPS to secure emergency medical and surgical treatment as well as routine, non-surgical medical care for my child while in camp at my expense. I give my permission for BCPS personnel to transport my child to a hospital for such a purpose. Parents/guardians and emergency contact persons listed on this form are authorized to pick my child up from camp if necessary. I understand that my child will not be released from the camp with any other person without my express written consent.

I shall indemnify and hold harmless BCPS and its Board or Education members, employees, and agents from any and all causes of action, claims, demands, losses, costs, damages, and expenses of any nature arising out of or in any way related to my child’s use of OEC facilities or attendance at OEC activities. I acknowledge that my child’s use of OEC facilities or attendance at OEC activities increases his or her risk of being exposed to, contracting, or transmitting COVID-19 or its symptoms. I further acknowledge that contracting COVID-19 or its symptoms may result in illness, permanent disability, or death. I understand my obligation to indemnify and hold harmless in this paragraph includes, but is not limited to, any and all causes of action, claims, demands, losses, costs, damages, and expenses of any nature arising out of or in any way related to my child contracting, being exposed to, or transmitting COVID-19 or its symptoms. I acknowledge that obligation includes paying the District’s reasonable attorney fees incurred in defending against any and all causes of action, claims, demands, losses, costs, damages, and expenses that meet the requirements of this paragraph. I acknowledge that I am signing below knowingly, intelligently, and voluntarily.
PARENT / LEGAL GUARDIAN signature. Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date * / MM / DD YYYY

STUDENT REGISTRATION AND HEALTH INFORMATION

STUDENT REGISTRATION AND HEALTH INFORMATION

GENERAL HEALTH QUESTIONS