Camper Last Name

    Camper First Name

    Camper Nickname

    Camper's Date of Birth

    Camper's School Grade in Fall 2020

    School Attending in Fall

    Male or Female
    MaleFemale

    Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult X-Large

    Home Address

    Camper lives with:
    MotherFatherOther

    If answered "other" to the above question, please explain.

    Mother's or guardian's first and last name

    Mother's or guardian's phone number

    Mother's or guardian's email address

    Father's or other guardian's first and last name

    Father's or other guardian's phone number

    Father's or other guardian's email

    Transportation Information - Families have busy lives and often make various transportation arrangements for their children, both dropping off and picking up from camp. To ensure that the children are only released to the proper adults, Pre-Vet and Vet Science Camp requires all children to be signed out and the individual picking them up must be on the approved pick up list provided by the parent AND show photo ID at the time of pick up. If camp attendees are permitted to drive, they will be allowed to sign themselves out; however, they are not permitted to drive to the field trip locations. To ensure your child's safety, please list below the individuals authorized to sign out your camper.

    Refund and Cancellation - For cancellations prior to May 1, a 100% refund is provided. Cancellations between May 1 and June 1, a 50% refund is provided. For cancellations after June 1, the total fee is forfeited. In the event that your child enrolls in camp and withdraws because of homesickness or is asked to leave because of misconduct, there will be no refund. We, the parent/guardian of the camper, have read and understand the terms and conditions of the Refund and Cancellation policy and agree to subscribe to them by checking the bow below.
    I agree

    Camper Dismissal - A camper whose behavior is disruptive to the camp program or harmful to himself/herself, others or the property of the camp or others will be dismissed at the discretion of the Camp Director, with no refund of fee. Upon dismissal, the parent/guardian must arrange for immediate pick up of the child, regardless of the location of the camp at the time of the incident. We, the parent/guardian of the camper, have read and understand the terms and conditions of the Camper Dismissal policy and agree to subscribe to them by checking the bow below.
    I agree

    Parent/Guardian Agreement and Waiver - We, the undersigned parents/guardians of the camper named on this application, acknowledge that we are fully aware that certain elements of danger are inherent in the activities sponsored by the Roanoke Valley SPCA, which are beyond the control of the agents, the land owners, employees and volunteers of Roanoke Valley SPCA and that participation in any program activities may entail unavoidable risk of personal injury, death and loss of or damage to property. We are aware of the types of activities in which the child will be participating during his/her stay and have been given ample opportunity to ask any questions which we may have about the camp the child will be participating in or the activities involved. We are aware of the dangers that are inherent in the operation of any child's camp and in the child's participation in all camp activities on or off premises of said camp.

    We grant permission to use any photograph or video for promotional use, knowing it will be done in good taste.

    We, the parent/guardian of the camper, have read and understand the terms and conditions of the Parent/Guardian Agreement and Waiver, and agree to subscribe to them by checking the bow below.
    I agree
    Date of Agreement

    In the event of an emergency, parents/guardians will always be contacted first. However, should neither parent/guardian be available, please list an alternative emergency contact's first and last name.

    Emergency Contact Phone Number

    Emergency Contact's relationship to the camper

    Insurance Carrier

    Insurance Group #

    Insurance ID #

    Health & Prescription Authorization - The health history is correct and complete as far as I know and the person herein described has permission to engage in all camp activities except as noted. I hereby give permission to the camp to provide routine health care, administer prescribed medications and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for insurance purposes. I give permission to the camp to arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization for the child named above. All prescription medication must be turned over to camp staff for handling and administration, in its original container with clear instructions. All Over-The-Counter medication must be turned over to camp staff with written instructions from parent/guardian regarding administration.

    We, the parent/guardian of the camper, have read and understand the terms and conditions of the Parent/Guardian Agreement and Waiver, and agree to subscribe to them by placing my name in the box below.
    I agree

    Date of Authorization

    Medication Allergies (Please List and describe if any.)

    Food Allergies (Please List and describe if any.)

    Other Allergies (Please list and describe reaction - including insect stings, hay fever, animal dander, etc if any.)

    Is this child taking medication on a routine basis?
    YesNo

    Medication(s) name, dosage, and reason for taking:

    Please list any and all restrictions placed on the camper's activity. Be sure to include food and activity restrictions.

    Which of the following has the camper had?
    MeaslesChicken PoxMumpsGerman MeaslesHepatitis AHepatitis BHepatitis CNone of these

    Is the camper current on all immunizations?
    YesNo

    Date of last Tetanus shot

    Name of Pediatrician

    Pediatrician's Phone Number

    Name of Dentist

    Dentist's Phone Number

    Name of Orthodontist

    Orthodontist's Phone Number

    Have any recent injury, illness of infectious disease?
    YesNo

    Have a chronic or recurring illness or condition?
    YesNo

    Ever been hospitalized?
    YesNo

    Ever had surgery?
    YesNo

    Have frequent headaches?
    YesNo

    Ever had a head injury?
    YesNo

    Ever been knocked unconscious?
    YesNo

    Wear glasses, contacts or protective eye wear?
    YesNo

    Have frequent ear infections?
    YesNo

    Ever passed out during or after exercise?
    YesNo

    Ever been dizzy during or after exercise?
    YesNo

    Ever had a seizure(s)?
    YesNo

    Ever had chest pain during or after exercise?
    YesNo

    Ever had high blood pressure?
    YesNo

    Able to swim?
    YesNo

    Ever had back problems?
    YesNo

    Ever had joint problems?
    YesNo

    Have an orthodontic appliance being brought to camp?
    YesNo

    Have any skin problems?
    YesNo

    Have diabetes?
    YesNo

    Have asthma?
    YesNo

    Had mononucleosis within the past year?
    YesNo

    Have problems with diarrhea or constipation?
    YesNo

    Have an eating disorder?
    YesNo

    Have a learning disability?
    YesNo

    If female, abnormal menstruation?
    YesNo

    If you checked yes for any of the above questions, please explain, noting the specific information.

    Are there any conditions that we should be aware of that may affect the camper's ability to participate in our programs?
    YesNo

    Please provide any additional information about the participant's behavior and physical, emotional or mental health about which the camp staff should be aware.

    By placing my name in the below box, I acknowledge that all of the above information is true and up-to-date.