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2. Vernon Township Summer Camp Emergency Form 2021
4. Camper's First Name*
5. Camper's Last Name*
6. Nick Name
8. Date of Birth*
9. Age*
10. Gender*
    -- Select One --MaleFemale
12. Primary Contact*
13. Relationship to Child*
14. Phone Number*
15. Phone Number
17. Secondary Contact*
18. Relationship to Child*
19. Phone Number*
20. Phone Number
22. Names of friends or relatives to contact if the above cannot be reached.
24. Alternate Contact 1:*
25. Relationship to Child
26. Phone Number*
28. Alternate Contact 2:*
29. Relationship to Child
30. Phone Number*
32. Physician to be called in case of emergency
34. Doctor's Name*
35. Doctor's Phone #*
36. Hospital Name*
37. Hospital Phone #*
39. Special Information(allergies, medical attention, medications that must be taken during camp hours, etc.):
41. For safety reasons all medication MUST be in original prescription bottle with dosage and name clearly marked. I hereby release and hold harmless Vernon Township, its officers, employees, staff and agents, from any and all liability resulting from or arising out of the administration of authorized medication or medications to my child during camp hours.
45. Camp staff has permission to apply:
47. Sunscreen*
    -- Select One --YesNo
48. Antibiotic Cream*
    -- Select One --YesNo
49. Insect Repellant*
    -- Select One --YesNo
51. My child has permission to eat snacks brought in by another camper or provided by the township.*
    -- Select One --YesNo
52. Does your child have a "nut" (peanut, tree nut, etc.) allergy?*
    -- Select One --YesNo
56. I authorize the Vernon Township staff to take whatever emergency medical measures are deemed necessary for the protection of my child while in their care. I give my consent, in the event that all reasonable attempts by authorized Township personnel to contact me or the other persons listed above have been unsuccessful, for:

    1)    The administration of any treatment deemed necessary by the physician listed above or, in the event the listed physician is not available, or by another physician; 

    2)    The transportation of my child by ambulance to Condell, Lake Forest or Highland Park Hospital, or any hospital reasonably accessible. 

    This authorization does not cover major surgery unless the medical opinions of two licensed physicians concurring in the need for such surgery are obtained prior to the performance of such surgery.

58. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
60. Electronic Signature*
61. Date*
    Date
Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit

* indicates a required field