Are camper(s) enrolled at ICS for the 2023-24 school year?* Number of current ICS students attending Basketball Camp:* Basketball camp
First ICS Student Name*
First
Last
Gender:* Male Female
Entering Grade:* Entering 4th Grade Entering 5th Grade Entering 6th Grade Entering 7th Grade Entering 8th Grade Entering 9th Grade
T-Shirt Size:* Youth Large Adult Small Adult Medium Adult Large Adult Extra Large
Second ICS Student Name*
First
Last
Gender:* Male Female
Entering Grade:* Entering 4th Grade Entering 5th Grade Entering 6th Grade Entering 7th Grade Entering 8th Grade Entering 9th Grade
T-Shirt Size:* Youth Large Adult Small Adult Medium Adult Large Adult Extra Large
Third ICS Student Name*
First
Last
Gender:* Male Female
Entering Grade:* Entering 4th Grade Entering 5th Grade Entering 6th Grade Entering 7th Grade Entering 8th Grade Entering 9th Grade
T-Shirt Size:* Youth Large Adult Small Adult Medium Adult Large Adult Extra Large
Fourth ICS Student Name*
First
Last
Gender:* Male Female
Entering Grade:* Entering 4th Grade Entering 5th Grade Entering 6th Grade Entering 7th Grade Entering 8th Grade Entering 9th Grade
T-Shirt Size:* Youth Large Adult Small Adult Medium Adult Large Adult Extra Large
Number of students who will attend ICS for 2022-23 school year:* First ICS Accepted Student Name*
First
Last
Gender:* Male Female
Entering Grade:* Entering 4th Grade Entering 5th Grade Entering 6th Grade Entering 7th Grade Entering 8th Grade Entering 9th Grade
T-Shirt Size:* Youth Large Adult Small Adult Medium Adult Large Adult Extra Large
Second ICS Accepted Student Name*
First
Last
Gender:* Male Female
Entering Grade:* Entering 4th Grade Entering 5th Grade Entering 6th Grade Entering 7th Grade Entering 8th Grade Entering 9th Grade
T-Shirt Size:* Youth Large Adult Small Adult Medium Adult Large Adult Extra Large
Third ICS Accepted Student Name*
First
Last
Gender:* Male Female
Entering Grade:* Entering 4th Grade Entering 5th Grade Entering 6th Grade Entering 7th Grade Entering 8th Grade Entering 9th Grade
T-Shirt Size:* Youth Large Adult Small Adult Medium Adult Large Adult Extra Large
Fourth ICS Accepted Student Name*
First
Last
Gender:* Male Female
Entering Grade:* Entering 4th Grade Entering 5th Grade Entering 6th Grade Entering 7th Grade Entering 8th Grade Entering 9th Grade
T-Shirt Size:* Youth Large Adult Small Adult Medium Adult Large Adult Extra Large
Address Student Address:*
Student Medical Information ICS requires that parents are responsible for providing the school with any prescription medication or special food that the student may require during the camp. An Allergy Reaction Care Plan, Asthma Inhaler Care Plan, or Generic Care Plan that is signed by your child’s physician is required prior to attendance at camp for the following conditions: Severe Allergies, Asthma and Seizure.
First student name:*
First
Last
First student date of birth:*
MM slash DD slash YYYY
First student height and weight:*
First student date of last Tetanus shot (if known):
MM slash DD slash YYYY
First Student: Does the student have allergies to food, medications and/or insects?* No Yes
Allergies which might require ICS staff to administer an Epi-pen require an Allergic Reaction Care Plan.
First Student: Please check all allergies that apply:* First Student: Please list the type of insect, describe the reaction and the treatment given:
(Reactions may include: coughing, wheezing, difficulty breathing, hives, local swelling, generalized swelling, rash, nausea, other)
First Student: Please list the type of food allergy, describe the reaction and list the treatment given:
(Reactions may include: coughing, wheezing, difficulty breathing, hives, local swelling, generalized swelling, rash, nausea, other)
First Student: Please list medication allergies, the type of medication, describe the reations and the treatment given:
(Reactions may include: coughing, wheezing, difficulty breathing, hives, local swelling, generalized swelling, rash, nausea, other)
First Student: My child has a history of asthma and needs an inhaler but does not require the use of an inhaler at camp according to his/her physician.* No Yes
First Student: My child has asthma and does require an inhaler or another medication that may be needed at camp.* No Yes (If yes, an Asthma Inhaler Care Plan is required. Please arrive early on the first day of camp to complete additional information.)
First Student: Please list the medication your child is taking for control of asthma.
First Student: Please list other health conditions. Type 'none' if this does not apply.*
First Student: My child has a history of seizures:* No Yes (If yes, please arrive early the first day of camp to complete a Seizure Care Plan.)
First Student: Please list type of seizure:
First Student: List all prescription medications your child takes at home or at school including emergency, occasional and routine medications. Type 'none' if this does not apply.*
Second student name:*
First
Last
Second student date of birth:*
MM slash DD slash YYYY
Second student height and weight:*
Second student date of last Tetanus shot (if known):
MM slash DD slash YYYY
Second Student: Does the student have allergies to food, medications and/or insects?* No Yes
Allergies which might require ICS staff to administer an Epi-pen require an Allergic Reaction Care Plan.
Second Student: Please check all allergies that apply: Second Student: Please list the type of insect, describe the reaction and the treatment given:
(Reactions may include: coughing, wheezing, difficulty breathing, hives, local swelling, generalized swelling, rash, nausea, other)
Second Student: Please list the type of food allergy, describe the reaction and list the treatment given:
(Reactions may include: coughing, wheezing, difficulty breathing, hives, local swelling, generalized swelling, rash, nausea, other)
Second Student: Please list medication allergies, the type of medication, describe the reations and the treatment given:
(Reactions may include: coughing, wheezing, difficulty breathing, hives, local swelling, generalized swelling, rash, nausea, other)
Second Student: My child has a history of asthma and needs an inhaler but does not require the use of an inhaler at camp according to his/her physician. No Yes
Second Student: My child has asthma and does require an inhaler or another medication that may be needed at camp. No Yes (If yes, an Asthma Inhaler Care Plan is required. Please arrive early on the first day of camp to complete additional information.)
Second Student: Please list the medication your child is taking for control of asthma.
Second Student: My child has a history of seizures: No Yes (If yes, please arrive early the first day of camp to complete a Seizure Care Plan.)
Second Student: Please list type of seizure:
Second Student: Please list other health conditions.
Second Student: List all prescription medications your child takes at home or at school including emergency, occasional and routine medications.
Third student name:*
First
Last
Third student date of birth:*
MM slash DD slash YYYY
Third student height and weight:*
Third student date of last Tetanus shot (if known):
MM slash DD slash YYYY
Third Students: Does the student have allergies to food, medications and/or insects?* No Yes
Allergies which might require ICS staff to administer an Epi-pen require an Allergic Reaction Care Plan.
Third Student: Please check all allergies that apply: Third Student: Please list the type of insect, describe the reaction and the treatment given:
(Reactions may include: coughing, wheezing, difficulty breathing, hives, local swelling, generalized swelling, rash, nausea, other)
Third Student: Please list the type of food allergy, describe the reaction and list the treatment given:
(Reactions may include: coughing, wheezing, difficulty breathing, hives, local swelling, generalized swelling, rash, nausea, other)
Third Student: Please list medication allergies, the type of medication, describe the reations and the treatment given:
(Reactions may include: coughing, wheezing, difficulty breathing, hives, local swelling, generalized swelling, rash, nausea, other)
Third Student: My child has a history of asthma and needs an inhaler but does not require the use of an inhaler at camp according to his/her physician. No Yes
Third Student: My child has asthma and does require an inhaler or another medication that may be needed at camp. No Yes (If yes, an Asthma Inhaler Care Plan is required. Please arrive early on the first day of camp to complete additional information.)
Third Student: Please list the medication your child is taking for control of asthma.
Third Student: My child has a history of seizures: No Yes (If yes, please arrive early the first day of camp to complete a Seizure Care Plan.)
Third Student: Please list type of seizure:
Third Student: Please list other health conditions.
Third Student: List all prescription medications your child takes at home or at school including emergency, occasional and routine medications.
Fourth student name:*
First
Last
Fourth student date of birth:*
MM slash DD slash YYYY
Fourth student height and weight:*
Fourth student date of last Tetanus shot (if known):
MM slash DD slash YYYY
Fourth Student: Does the student have allergies to food, medications and/or insects?* No Yes
Allergies which might require ICS staff to administer an Epi-pen require an Allergic Reaction Care Plan.
Fourth Student: Please check all allergies that apply: Fourth Student: Please list the type of insect, describe the reaction and the treatment given:
(Reactions may include: coughing, wheezing, difficulty breathing, hives, local swelling, generalized swelling, rash, nausea, other)
Fourth Student: Please list the type of food allergy, describe the reaction and list the treatment given:
(Reactions may include: coughing, wheezing, difficulty breathing, hives, local swelling, generalized swelling, rash, nausea, other)
Fourth Student: Please list medication allergies, the type of medication, describe the reations and the treatment given:
(Reactions may include: coughing, wheezing, difficulty breathing, hives, local swelling, generalized swelling, rash, nausea, other)
Fourth Student: My child has a history of asthma and needs an inhaler but does not require the use of an inhaler at camp according to his/her physician. No Yes
Fourth Student: My child has asthma and does require an inhaler or another medication that may be needed at camp. No Yes (If yes, an Asthma Inhaler Care Plan is required. Please arrive early on the first day of camp to complete additional information.)
Fourth Student: Please list the medication your child is taking for control of asthma.
Fourth Student: My child has a history of seizures: No Yes (If yes, please arrive early the first day of camp to complete a Seizure Care Plan.)
Fourth Student: Please list type of seizure:
Fourth Student: Please list other health conditions.
Fourth Student: List all prescription medications your child takes at home or at school including emergency, occasional and routine medications.
Emergency Contact Name*
First
Last
Name
First
Last
Home Phone
Cell Phone*
Cell Phone
Insurance Information Policy Holder*
Insurance Company*
ID/Policy Number*
Physician's Name*
Physician's Phone*
Authorization, Waiver and Release I the undersigned do hereby release Immanuel Christian School and its employees from any rights and claims for injury resulting in participation in camp activities. I understand my son/daughter will be engaging in physical activity during the program that contains inherent risk of physical injury. Furthermore, I understand that in the event of an emergency the school will call “911” and my son/daughter will be taken to the nearest hospital and that every effort will be made to contact me. I hereby authorize any physician or hospital to render medical treatment which in his/her judgment, may be necessary in the care of my child. I certify that all the information on this form is complete and that, to my knowledge, my child requires no additional medical services during the hours of basketball camp. I understand that I may be required to provide additional information to the school regarding specific health conditions. I further, agree to release, indemnify, and hold harmless any staff or trained volunteer from lawsuits, claims expenses demands or actions, etc., against them for helping this student use medications for which permission is expressly given on this form. Furthermore, I understand it is my responsibility to keep the school informed of any changes to the information contained on this form. I also give permission to have my student’s picture used for promotional purposes such as Facebook or the school website. I indicate my agreement and understanding by checking the box below.* Parent Signature:*
First
Last
Parent Email:*
Parent Work Phone:
Parent Cell Phone:*
Date*
MM slash DD slash YYYY
Total Cost For Basketball Camp:
$0.00
Please note you will be redirected to Paypal when you click "submit" to complete your RSVP. Basketball Camp registration is confirmed when payment is received. Thank you!
