Camp HEAL Camper Application

Camp HEAL Camper Application

Camper Application Deadline is September 1, 2025 or when enrollment number is reached. Camper Space is Limited. A child must be ages 6-12 to attend Camp HEAL.
Child's Name*
Date of Birth*
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please check*

MaleFemale
T-Shirt Size*
School Child Attends*
Grade*
Parent/Guardian Name*
Parent/Guardian Contact Numbers
Home
Please enter a valid phone number.
Cell*
Please enter a valid phone number.
Work
Please enter a valid phone number.
Other
Please enter a valid phone number.
Alternate Contact Name and Number*
Child lives with*
Relationship*
Please list persons allowed to pick up child. Upon pick-up, please present the Parent Lanyard with Camper information for verification.
Name*
Name
Name
Name
Please complete all of the following information about the child attending Camp HEAL. If not applicable, please write "none."
Allergies (include medications, foods, environmental substances)*
Medication Currently Taking (include doses and frequency)*
Medical Conditions or Diagnoses*
Special Needs*
Physician*
Physician's Phone Number*
Please enter a valid phone number.
Child Experienced Death of (Name)*
Date of this death was*

MonthDayYear
Date
Relationship to child was*
*This information is important for us to know*
Any specific behaviors or issues you have noticed since this death? *
Other important information you want us to know.
Signature*

Clear
Authorization to Administer Medication
Child's Name

First NameLast Name
Date

MonthDayYear
Date
Doctor's Name

First NameLast Name
Doctor's Phone Number
Please enter a valid phone number.

Medication Details

	Name of Medication	Dosage	Time to be Given
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6

Parent/Guardian's Signature

Clear
Parent/Guardian's Phone Number
Emergency Contact Person

First NameLast Name
Emergency Contact Phone Number
Authorization for Disclosure of Image/Testimony for Commercial Marketing Purposes
Camper Name

First NameLast Name
Camper Date of Birth

MonthDayYear
Date
Camper Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby authorize Archbold Medical Center, together with its employees, agents and contractors, to use or disclose private information or images about me or my treatment as noted in this Authorization for the marketing purposes as noted below.

Information to be Used or Disclosed:
- My visual image (example: my photograph)
- Camp HEAL images/statements
Person(s) Authorized to Make the Use or Disclosure:

The following persons or class of persons are authorized to make the use or disclosure of this information/image, etc.
- Archbold Medical Center (including Public Relations or Marketing or Fundraising Departments)
- Archbold Hospice/Camp HEAL
Recipient(s) of Use or Disclosure:

This information may be used or disclosed to or by the following persons or class of persons:
- To media or print networks and the public at large via Internet, TV, radio, billboard, letter, or any other marketing correspondence/forum
Purpose(s) of the Use or Disclosure:

Marketing for Archbold Medical Center to try to encourage the use of Archold Medical Center services and treatment facilities and products by the general public and/or community.

Expiration:

This Authorization will expire at the end of Camp HEAL 2025.
Camper's Name

First NameLast Name
Date

MonthDayYear
Date
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature

Clear
Relationship to Camper (Parent or Guardian)
Should be Empty:

Camp HEAL Camper Application

Authorization to Administer Medication

Authorization for Disclosure of Image/Testimony for Commercial Marketing Purposes