Date_____________________
Camper's Name____________________________________Age:_____ Date of Birth:__________ Sex: M______F______
Address:___________________________________________City________________________
State___________ZIP_________ Phone_________________Cell Phone:________________E-Mail_______________________
Allergies:______________________________________________________________________
Medications:___________________________________________________________________
Immunizations(latest date) MMR______DPT_____Polio_____Tetanus_____ HEB_____ HIB_____ Chicken Pox_____ (immunization dates must be accompanied by a copy of the imunization records before confirmation) Please list any medical conditions including ADHD or any other behaviorial conditions within the last 3 years.______________________________ ___________________________________________________________________
Doctor's Name___________________________________________Phone__________________ *This information is required by NYS law and the Tioga County Health Department Camp Week (please circle weeks attending): 1 (7/9-13) 2 (7/16-20) 3 (7/23-27) 4 (7/30-8/3) 5 (8/6-10) 6 (8/13-17)
Please provide an alternative contact in the event you can not be reached.
Emergency name______________________________________________Phone_________________ I give my permission for________________________ to take part in the Town of Owego Summer Recreation Camp provided by Waterman Conservation Education Center. This child, to the best of my knowledge, is in good physical condition and is capable of outdoor physical activities. I understand that outdoor activities have an inherent risk factor. I give permission to the Waterman staff and volunteers and/or hospitals to administer proper medical assistance to the above named participant. I agree not to hold the Fred L. Waterman Conservation Education Center, Inc. or any of their agents responsible in the event of an injury.
________________________________________________ Parent or Guardian (Please Print) __________________________________________ ____________ Signature of Parent or Guardian Date
Please send filled out application to: The Town of Owego Rec. Camp Waterman Center 403 Hilton Road Apalachin, NY 13732