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MARYLAND STATE DEPARTMENT OF EDUCATION - Office of Child Care

EMERGENCY FORM

The tuition is $230 weekly. The $75 deposit is credited toward weekly tuition. After the deposit is paid each week will have a balance of $155 that is due the day before each camp week starts. Payments can be made on the total deposit due. Deposits are due in full by 6/24/22. Please call with questions on the deposit.

INSTRUCTIONS TO PARENTS:

(1) Complete all items on this side of the form. Sign and date where indicated.

(2) If your child has a medical condition which might require emergency medical care, complete the back side of the form. If necessary, have your child’s
health practitioner review that information.

NOTE: THIS ENTIRE FORM MUST BE UPDATED ANNUALLY.

When parents cannot be reached, list at least one person who may be contacted to pick up the child in an emergency:

(1)

Name:

Telephone:

Address:

(2)

Name:

Telephone:

Address:

(3)

Name:

Telephone:

Address:

Child’s Physician or Source of Health Care

Telephone

Address:

In EMERGENCIES requiring immediate medical attention, your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. Your signature
authorizes the responsible person at the child care facility to have your child transported to that hospital.

Signature of Parent/Guardian

Date

Attach immunizations or health forms here

Child's Name:

Enrollment Date

Hours & Days of Expected Attendance

Child’s Home Address

Mother’s Name

Home Telephone

Mother’s Employer/School

Mother’s Home Address
(If different from above)

Work Telephone

Cellular Phone

Beeper

Father’s Name

Home Telephone:

Father’s Employer/School

Father’s Home Address
(If different from above)

Work Telephone

Cellular Phone

Beeper

Name of Person Authorized to Pick Up Child (daily)

Address:

ANNUAL UPDATES

OCC 1214 (Revised 6/2020) - Side 1 of 2 - All previous editions are obsolete.

INSTRUCTIONS TO PARENT:

(1) Complete the following items, as appropriate, if your child has a condition(s) which might require emergency medical care.

(2) If necessary, have your child’s health practitioner review the information you provide below and sign and date where
indicated.

Child’s Name:

Date of Birth:

Medical Condition(s):

Medications currently being taken by your child:

Date of your child’s last tetanus shot:

Allergies/Reactions:

EMERGENCY MEDICAL INSTRUCTIONS:

(1) Signs/symptoms to look for:

(2) If signs/symptoms appear, do this:

(3) To prevent incidents:

OTHER SPECIAL MEDICAL PROCEDURES THAT MAY BE NEEDED:

COMMENTS:

Note to Health Practitioner:

If you have reviewed the above information, please complete the following:

Name of Health Practitioner

Date

Signature of Health Practitioner

Telephone Number

OCC 1214 (Revised 6/2020) - Side 2 of 2 - All previous editions are obsolete.

COVID 19 STATEMENTS

Please initial each of the following

TEMPERATURES WILL BE CHECKED AT ARRIVAL. HANDS WILL BE SANITIZED HOURLY

Camp tuition is not reduced for days missed due to COVID-19 exposures outside camp. Deposits are not refundable due to missed camp weeks.
Camp tuition will be refunded if camp is closed due to a mandate to close by the health department.
Masks will be worn indoors during camp. Masks will not be worn when children are outdoors in the back play area. We will follow county mandates for park visits.

**Students may take masks breaks for eating and drinking and in the restroom. Masks must be on at all other times

Emergency Form

EMERGENCY FORM

INSTRUCTIONS TO PARENTS:

ANNUAL UPDATES

INSTRUCTIONS TO PARENT:

EMERGENCY MEDICAL INSTRUCTIONS:

Note to Health Practitioner:

Kingdom Care Camp 2022 Enrollment Form (p.3)

Please make additional copies for each camper

By applying to Kingdom Care Camps, I accept the following terms and conditions:

READ CAREFULLY

Kingdom Care Camp 2022 Enrollment Form (p.4)

2022 Sessions and Dates (place an X beside the sessions your camper will be attending)

COVID 19 STATEMENTS

EMERGENCY FORM

INSTRUCTIONS TO PARENTS:

ANNUAL UPDATES

INSTRUCTIONS TO PARENT:

EMERGENCY MEDICAL INSTRUCTIONS:

Note to Health Practitioner:

Kingdom Care Camp 2022 Enrollment Form (p.3)

Please make additional copies for each camper

By applying to Kingdom Care Camps, I accept the following terms and conditions:

**READ CAREFULLY**

Kingdom Care Camp 2022 Enrollment Form (p.4)

2022 Sessions and Dates (place an X beside the sessions your camper will be attending)

COVID 19 STATEMENTS

READ CAREFULLY