Life in the Sea (July 22 – 26)

Parent or Guardian Information

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• Address 2:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Phone:
• * Cell Phone:
• * Relationship to Child

• Blithewold Camp Sequoia Authorization Statement: “This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted. I hereby give permission to the medical personnel selected by the camp director to act in the best interest of my child in the case of an emergency. Every effort will be made to contact a responsible adult. I also give permission for routine first aid care by the camp staff and grants permission for the staff to give the medical provider the name and policy number of the medical insurer. I also give permission for the use of pictures, video, and statements by the campers in Blithewold promotional materials.”

• *

  Please click below to agree to the above Blithewold Camp Sequoia authorization statement.

  • Yes, I agree with the above statement.

• Promo Code

  Enter Code: Apply

• Fee

  Type	Fee
  Non-member (Automatically enrolled to a 12-month Blithewold Household Membership)	$240.00
  Blithewold Member	$190.00

Camper Information and Health History

• * Campers Name
• * Campers Age
• * Dietary Restrictions (Type N/A if none)
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• * Allergies (Food, insects, plants, drug, ect.) (Type N/A if none)
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• * Chronic or recurring illness or medical conditions (Type N/A if none)
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• * Current Medications (Type N/A if none)
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• * Medication to be administered at camp (Type N/A if none)
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• Health History (Please check all the apply)

  • Allergy to Other Drugs
  • Allergy to Penicillin
  • Asthma
  • Chicken Pox
  • Convulsions
  • Diabetes
  • Frequent Ear Infections
  • Hay Fever
  • Heart Defect/Disease
  • Hypertension
  • Measles
  • Mononucleosis
  • Mumps
  • Severe Allergy to Insect Stings
  • Severe Allergy to Poison Ivy

• “This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted. I hereby give permission to the medical personnel selected by the camp director to act in the best interest of my child in the case of an emergency. Every effort will be made to contact a responsible adult. I also give permission for routine first aid care by the camp staff and grants permission for the staff to give the medical provider the name and policy number of the medical insurer. I also give permission for the use of pictures, video, and statements by the campers in Blithewold promotional materials.”

• Additional health information or anything else we need to know about your child. (Such as any behavior or learning disabilities, that could affect your child's camp experience.)
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Additional Camper Information and Health History

You may add a maximum of 5

Camp Pickup Authorization (List of people authorized to pick up your camper)

• For the safety of your child(ren), they may be picked up from camp ONLY by those individuals specified by you in writing on this authorization release form. All authorized persons must show a picture ID or some type of valid identification, which will be requested by Blithewold camp staff. In emergencies, a telephone call authorization may be acceptable. In some cases, we will call a number you have given us previously to verify that it is you making the call.

• * 1.) Full Name
• * Phone:
• * Relationship to Child(ren)
• 2.) Full Name
• Phone
• Relationship to Child(ren)
• 3.) Full Name
• Phone
• Relationship to Child(ren)