Mosholu Day Camp
Staff & Activities
Born 2009 & 2010
Born 2007 & 2008
Special Needs Ages 5-16yrs
Teen Adventures 2003-06
Camper Information Form
Phone Number you can be reached in an emergency
Emergency Contact Name
Other than you
Other Phone Number
Emergency Contact Phone Number
MENINGOCOCCAL MENINGITIS VACCINATION RESPONSE
New York State Public Health Law requires that a parent or guardian of campers who attend a children’s camp
to complete the following.
Check one box and sign below.
My child has had meningococcal meningitis immunization within the past 10 years.
[Note: If your child received the meningococcal vaccine available before February 2005 called Menomune™, please note
this vaccine’s protection lasts for approximately 3 to 5 years. Revaccination with the new conjugate vaccine called
Menactra™ should be considered within 3-5 years after receiving Menomune™.]
Read and check the following...
I have read, or have had explained to me, the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that my child has not or will not obtain immunization against meningococcal meningitis disease at this time.
SUN SCREEN & FIRST AID TOPICAL OINTMENT CONSENT
Check to agree
I consent to have my child use the sunscreen s/he has brought or the camp has supplied, which is approved by the FDA for over the counter use to avoid overexposure to the sun. My child may be assisted by camp counselor staff if s/he requests.
I consent to have the camp staff use topical ointment for wounds, bug bites, etc. in the treatment of basic first aid.
List any allergies (food or otherwise) or specific medical information you think we should be aware of
Specific Camper Needs
Does your child have any specific needs such as behavioral issues or medical issues that will hinder their ability to have a successful summer?
Does your child have an IEP in school?
Please make sure that the camp gets a copy of the IEP so that we can make sure that we are able to meet the campers needs.
Please list any medications (prescription or non prescription) your child is currently taking. Keep in mind that the camp can not administer medication.
Month/ Year of last Tetanus Shot- If never please write n/a
If you request that your child sign him/her self out and walk home alone, please give a note to the bus counselor on the first day of program.
Please list anyone authorized to pick up and sign out your child from camp.
(Do not forget to include yourself).
Don't forget to include yourself
Please list any person or a circumstance that you may want us to be aware of when bringing your child home. This should include but not be limited to an order of protection or anyone not authorized to pick up your child:
Tentative Trip Information
Teen Adventure Trip Dates and Locations
June 30- Bear Mountain- Swim/ Field Games
July 3- Splash Down- Water Park Activities
July 5- Rockland Boulders Baseball Game
July 6- Camel Beach Late Night
July 10- The Rock Club- Rock Climbing
July 11- Rockland State Park- Swim/ Field Games
July 12- July 14- 3 day trip to Boston
July 18- SplashPlex- Water Park Fun
July 19- Go Karting
July 20- Great Adventure Over Night
July 25- FDR Park- Swim/ Field Games
July 26- 27 Club Getaway Overnight
July 31- Lake Compounce- Late Night
Aug 2- Deep Sea Fishing
Aug 3- Horseback Riding- Overnight
Aug 8- Mountain Creek Amusement Park
Aug 9- Broadway Show
Aug 11- High Ropes Airial Park
Aug 14- Turtle Back Zoo
Aug 15- Tomahawk Lake
Aug 16- Dorney Park Late Night
Aug 17- Bear Mountain Park- Swim/ Field Games
Blazer Trip Dates and Locations
June 30- Rockland State Park- Swim/ Field Games
July 3- FDR Park- Swim/ Field Games
July 5- Lake Quassy (Late Night)
July 7- Splash Down Water Park Activities
July 10- Zoom Flume Late Night
July 12- Rockland Boulders Baseball Game
July 14- Lake Welch
July 17- Bear Mountain Park- Swim/ Field Games
July 19- Rye Playland Amusement Park
July 21- Pole Position Raceway
July 26- Sahara Sam's Oasis (Late Night)
July 31- White Water Rafting
Aug 2- Camel Beach (Late Night)
Aug 7- Castle Fun Center
Aug 9- Aerial Park (3 day Overnight)
Aug 10- Splish Splash (3 day Overnight)
Young Blazer Trip Dates and Locations
July 6- Rockland State Park-- Swim/ Field Games
July 11- Bear Mountain-- Swim/ Field Games
July 13- Splash Down Water Park (Overnight)
July 18- Sesame Place Late Night
July 20- Beauty & The Beast
July 25- Castle Fun Center
July 27- Camel Beach Late Night
Aug 1- Palisades Indoor Ropes
Aug 3- FDR State Park-- Swim/ Field Games
Aug 8- Luna Park (3 day overnight)
Aug 9- Wild West City (3 day overnight)
In typing my name below, I accept all terms of enrollment and give permission for my child to participate in all activities including trips away
from the campsite. I understand that the camper cannot attend with out an updated & signed medical form and that
MMCC assumes no responsibility for personal property. I agree that photos taken by the camp may be used for
publicity purposes and I agree to make payment in full before the start of the session. I also give the camp the
authority to obtain necessary emergency medical treatment for my child.
Days until camp