Candlewood Knolls Children’s Program Summer Camp


(One form per child)

Name of Parent(s) or Guardian(s) with whom child resides:


Medical Information:


Current Medical Information:

(Medications, Food, Tape, Sun block, Insect bites/stings, etc.)

Permissions given to a CKCP Staff member


Emergency Numbers:

Please give the name, address and phone number of 2 CK residents who should be contacted in the event of an emergency,
or to whom your child may be released to in case the parents are not available:


Departure Procedure:


Emergency Medical Release:

Please be advised that all campers must carry their own medical coverage. All CKCP staff are first aid and CPR certified and will take whatever emergency medical measures are deemed necessary to assure the safety of each camper. This may include transportation by emergency vehicle to the nearest medical facility. In the event of a medical emergency, you will be notified immediately. If emergency medical care is deemed necessary and I cannot be contacted, I authorize the staff to act on my behalf in granting permission for my child to receive emergency treatment.

(Signature of parent or guardian)