Phone: (443) - 585 - CAMP
Camper Supplemental Information Form
) Required Field
Indicates required field
Date of Birth (MM/DD/YYYY)
Non swimmer (unable to swim)
Beginner (Shallow Pool End)
Emergency Contact Information
1st Emergency Contact (Parent or Legal Guardian)
2nd Emergency Contact (Other than Parent Above)
Does child attend school? (public or private)
If no, then a copy of immunization records must be provided before the first day of attendance
Name of School
Date of Last Tetanus Shot (MM/DD/YYYY)
Insurance Policy #
Physician's Phone Number
Are there any health problems including physical, psychiatric, or behavioral problems of which we need to be aware? If no, enter N/A. If yes, please explain.
Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child's camp experience is positive? If no, enter N/A. If yes, please explain.
Emergency Medical Authorization
I give Terrapin STEM Camp permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment by a certified staff member of Terrapin STEM Camp. I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I authorize Terrapin STEM Camp to obtain immediate medical care and give consent to the hospitalization and performance of necessary diagnostic tests upon, the use of surgery on, and/or the administration of drugs to his/her child or ward if an emergency occurs when he/she cannot be located immediately. It is also understood that this agreement may only cover those situations which are true emergencies and only when he/she cannot be reached. I understand that the provider will take every effort to contact me and/or my designated emergency contacts.
I/we will be responsible for payment of medical expenses with the Insurance provider and Policy # given on this page.
I agree to the terms outlined in this Emergency Medical Authorization
Parental Agreements & Consent Authorization
1) Children who have a fever or other flu-like symptoms must refrain from attending camp for twenty-four hours after the last evidence of illness. Students who become ill at camp must be picked up by their parent/guardian as soon as possible.
2) Within twenty-four hours, Terrapin STEM Camp must be notified if a camper or a member of his immediate household contracts a communicable disease.
3) Terrapin STEM Camp provides limited healthcare for sick or injured students. Due to Maryland health regulations, Terrapin STEM Camp does not administer prescriptive or non-prescriptive drugs, except in the case of metered dose inhalers (hand-held devices) and epinephrine pens. We do provide ice packs and bandages, as needed. Parents will be notified of any healthcare their child receives.
4) In the event that a parent/guardian cannot be reached in an emergency, Terrapin STEM Camp administrators will contact local emergency services to obtain treatment for the child. The child will be transported to a local medical facility and will receive care under the direction of licensed medical professionals. Parents will be financially responsible for any care their child may receive.
5) Parents/Guardians will provide correct medical information for their child. Terrapin STEM Camp will be notified if a child’s information changes.
6) Terrapin STEM Camp students will participate in field sports, camp crafts, indoor/outdoor games, hiking, swimming and other camp activities. All activities include a measure of risk. Risks may include a loss or damage to personal property, injury or fatality. Registration for Terrapin STEM Camp assumes parental acknowledgement of these risks for the child. Terrapin STEM Camp follows safety procedures, but assumes no liability for any loss or damage as a result of student participation. Terrapin STEM Camp, its agents and employees will be held harmless from any liability which may arise out of or in connection with Terrapin STEM Camp programming. These terms shall serve as a release and assumption of risk for any minors.
I hereby grant permission for my child to be photographed and/or videotaped while participating in programs and activities at Terrapin STEM Camp, which may be published online or on print to illustrate camp experience. I hereby consent to use of my and/or my minor child in such materials to be exhibited and used for advertising, trade purposes, solicitation of patronage, promotional purposes, or other similar purposes in media such as photograph, videotape, television program, motion picture, tape recording, or other similar media.
1) A minimum deposit of $110 as well as a $10 per week processing fee per camper must accompany this application. Applications submitted after May 15th must include payment in full.
2) For campers who withdraw on or before May 15th, $110 will be retained as a non-refundable administrative fee along with the $10 per week processing fee. For campers who withdraw May 16th through June 10th, 50% of tuition fees is refundable. Starting June 11th, NO tuition will be refunded. If tuition has not been paid for registered weeks, campers will be billed for the tuition. THERE ARE NO EXCEPTIONS!
3) After the May 15th payment deadline, accounts not paid in full will be charged a late fee of $10 per registered week. We reserve the right to drop any accounts not paid in full by June 10th without refund.
4) Registration fees may be transferred to other weeks of the 2016 Terrapin STEM Camp season, depending on the availability of openings.
5) After March 15th or May 15th (depending on the registration preference), any remaining account balance will be billed to the credit card on file.
6) Fees will be refunded if a camper placed on the waiting list is not accepted into the program.
7) Terrapin STEM Camp has one-week programs and under no circumstances may a week/weeks be split between campers.
8) Parents/Guardians should ensure Terrapin STEM Camp has received mailed applications by phoning the office at
(443)- 585-CAMP or by emailing a confirmation request to firstname.lastname@example.org. Terrapin STEM Camp is not responsible for applications lost in the mail.
9) Terrapin STEM Camp processes applications in order of arrival. Parents/Guardians will be notified by email, mail or phone if their camper is on a waiting list. Upon acceptance, Parents/Guardians will be sent a confirmation letter or email.
Terrapin STEM Camp promotes an atmosphere of collaboration, acts of respect and good sportsmanship. We reserve the right to dismiss any camper when it is in the best interest of the child or the camp. In the case of such dismissal, refunds are at the sole discretion of the executive director.
1) Be respectful to other campers, to staff and to camp property. Parents/Guardians will be charged for any damages their camper may cause to equipment or to the facility.
2) Follow directions and practice safe conduct.
3) Remain within sight of camp staff or inform camp staff if, for any reason, they need to move to another location.
4) Remain on camp premises or at a location designated by camp staff.
5) Wear close-toed shoes and active-wear clothing to camp.
6) Bring modest swimwear and a towel to camp on designated swim days.
7) Share any concerns they may have regarding personal health, safety or welfare at camp or concerns they may have that affect the whole group.
8) Be aware of and will follow Terrapin STEM Camp rules and procedures.
9) Take responsibility for their actions.
I agree to the terms outlined in this Parental Agreements & Consent Authorization
I certify that I have read and agree to the terms and conditions as outlined above and I also certify that to the best of my knowledge, the supplied information is true, accurate and complete.
Terrapin STEM Camp is
not affiliated with the University of Maryland.
© COPYRIGHT 2015. ALL RIGHTS RESERVED.