Profile and Health Form

Camper Information

Camper full name*

Camper preferred name or nickname

Camper date of birth*

Camper gender*

Camper t-shirt size*

Address*

City*

State*

Zip*

Please select highest grade completed by June 2026*

How did you hear about UEC summer camps?*

Parent/Guardian Information

Parent/Guardian 1 Name*

Parent/Guardian 1 best daytime contact number*

Email address to receive summer camp information*

Alternate contact name*

Alternate phone number (in the event the best number is unavailable)*

Parent/Guardian 2 Name

Parent/Guardian 2 best daytime contact number

Parent/Guardian 2 alternate contact name

Parent/Guardian 2 alternate phone number

Parent/Guardian 2 address (if different)

Parent/Guardian 2 city

Parent/Guardian 2 state

Parent/Guardian 2 zip code

Emergency Contact Information

Please list, in order, the people you'd like our staff to call in the event of an emergency. Please include parent(s)/guardian(s) as applicable.

Emergency Contact 1*

Emergency Contact 1 phone number*

Emergency Contact 1 relationship to camper*

Emergency Contact 2*

Emergency Contact 2 phone number*

Emergency Contact 2 relationship to camper*

Emergency Contact 3*

Emergency Contact 3 phone number*

Emergency Contact 3 relationship to camper*

Emergency Contact 4

Emergency Contact 4 phone number

Emergency Contact 4 relationship to camper

People authorized to pick up my child (please list first and last name of all authorized persons)*

Sunscreen/Insect Repellent Authorization

I authorize Urban Ecology Center staff to apply sunscreen to my child*

I authorize Urban Ecology Center Staff to allow my child to self-apply sunscreen*

My child may use any sunscreen (SPF 30) provided by Urban Ecology Center*

My child may only use sunscreen I provide (I will bring it to camp)

If your child is bringing sunscreen from home, what brand?

I authorize Urban Ecology Center staff to apply insect repellent to my child*

I authorize Urban Ecology Center Staff to allow my child to self-apply insect repellent*

My child may use any insect repellent (25% DEET) provided by Urban Ecology Center*

My child may only use insect repellant I provide.(I will bring it to camp)

If your child is bringing insect repellant from home, what brand?

Physician and Insurance Information

Physician name (first, last)*Physician/medical facility addressPhysician/medical facility phone number

Check this box if camper is covered by health insurance.

Health insurance company name

Policy holder's name

Health insurance policy number

Health History & Emergency Care Plan

Select any special medical condition(s) your child has. If your child has more than one, hold the Ctrl key (PC) or Command key (Mac) while clicking each option.*Please provide detail for gastrointestinal concerns, feeding concerns, and/or other conditions requiring special care.Allergies*Please specify allergies here

If your child carries an EpiPen (or generic epinephrine injector), please select this box Checkbox

If your child carries an inhaler, please select this box.checkbox

If your child must take or use prescription or non-prescription medication during summer camp programming and under supervision or administration by Urban Ecology Center Staff, an "Authorization to Administer Medication" form must be completed and on-file prior to the time of medication administration. If your child is allergic to milk, submit a statement from your medical professional including acceptable alternative(s).

Triggers that may cause problems (please be specific.) If none, please enter "none"*Signs or symptoms to watch for (please be specific). If none, please enter "none"*Steps Urban Ecology Center staff should follow. If prescription or non-prescription medications are necessary, a copy of Authorization to Administer Medication form must be completed and on-file. If none, please enter "none"*Identify Urban Ecology Center staff to whom you have given specialized training / instruction to help treat symptoms. If none, please enter "none"*When should we call parents/guardians/emergency contacts if symptoms aren’t improving with treatment? If none, type “none”*When to consider that the condition requires emergency medical care or reassessment. If none, please enter "none"*Additional information that may be helpful to Urban Ecology Center staff. If none, please enter "none"*

Immunization Records - Important Notes

1

Immunization information is required to be submitted ON THIS FORM at the time of registration. If your form is not complete, you will be asked to complete a duplicate form. Do not send a separate immunization form.

2

Immunization records are required by state law. The information you provide will only be used to make sure your child meets these requirements.

3

If you do not have your child’s immunization record, please contact your doctor, the Wisconsin Immunization Registry, or your local health department to obtain a copy.

4

If your child has attended camp before, their immunization records have not been retained.

5

If your child does not meet all immunization requirements, you may request a waiver for health, religious, or personal conviction reasons. To do this, please enter N/A where appropriate below and complete the waiver form available on the Wisconsin DHS website: https://www.dhs.wisconsin.gov/forms/f4/f44192.pdf.

Complete the immunization history below by listing the month, day and year your child received each of the immunizations. Do not use a check mark except to answer the questions about chickenpox, Tdap, or Td. If you do not have an immunization record for your child at home, contact your doctor or public health department to obtain it.

Enter the complete date(s) of any DTaP/DTP/DT/Td (Diphtheria, Tetanus, Pertussis) immunizations your child has received*Please enter the type of adolescent booster your child has received for Diphtheria, Tetanus, Pertussis (Tdap or Td)Enter the complete date(s) of any Polio immunizations your child has received*Enter the complete date(s) of any Hepatitis B immunizations your child has received*.Enter the complete date(s) of any MMR (Measles, Mumps, Rubella) immunizations your child has received*Enter the complete date(s) of any Varicella (chickenpox) immunizations your child has received*

If your child has a history of Varicella/chickenpox disease, you must submit attestation from your child's physician to verify exemption from the Varicella vaccine requirement. Please use the form: https://dhs.wisconsin.gov/forms/f4/f44192.pdf

If your child has had a blood test (titer) that shows immunity (had disease or previous vaccination) for any of the following, enter the disease and provide laboratory report(s): Varicella, Measles, Mumps, Rubella, Hepatitis B

If your child does not meet all the vaccination requirements above, please check this box, then complete and sign the Student Immunization Record and submit to Urban Ecology Center by June 1, in advance of your child attending camp.

Child Behavior Questionnaire

Please complete the questions below to help us understand your child and to best work with them for a successful program. This information is shared with the staff who will be working with your child.

Help your child have the best day possible by sharing tips and tools to help them regulate when things get tough.

Please indicate the most common behavior/personality demonstrated by your child (examples: easy-going, shy, unsure of new situations, verbally aggressive, needs direction, etc*Please describe your child on their best days*Please describe your child on their worst days*Please indicate the types of activities your child enjoys (examples: arts & crafts, sports & games, dancing, fishing, nature hikes, swimming, music, board games, etc)Please describe any activities that should be excludedDoes your child have any fears that could impact our adventures? (if yes, please explain)Please indicate any other information you feel our staff would benefit from knowing about your child, especially if they have a behavior plan or IEP that helps support them during the school year

Swim Ability Designation

Please choose the category below that best describes your child's swimming ability*

Non-Swimmer: no experience swimming, not to be allowed in the water
Beginner: little experience swimming, and comfortable in the water
Intermediate Swimmer: comfortable swimming, putting head under water and basic strokes
Advanced Swimmer: can walk up to waist in the water, fully submerge head (comfortable with water near their face), swim 100 feet without stopping (stopping includes touching the ground or lack of forward motion), can float or tread water for 2 minutes

I authorize Urban Ecology Center Staff to transport my child on Urban Ecology Center buses (check box if yes)*

Checkbox

Summer Camp Liability Waiver and Release

I give my full permission for my child to attend the summer camp at the Urban Ecology Center, including public parks, and participate in all phases of activities, which may include canoeing, kayaking, climbing, hiking, fishing, biking and swimming, unless otherwise specified on the Health Form. I have read the camp brochure and all camp registration information and agree to cooperate with all regulations regarding registration and health forms to be completed. I hereby grant permission for hospitalization and emergency treatment for my child if needed. I either have appropriate insurance or, in its absence, agree to pay all costs of medical services.

I give permission for an Urban Ecology Center staff member to administer any medication that may be prescribed to my child. I understand that Health History, Emergency Care Plan and Immunization record are required for day camps in compliance with Wisconsin Administrative code and personal information may be used for secondary purposes.

In consideration for my child’s participation in summer camp at Urban Ecology Center, and other good and valuable consideration, the receipt and sufficiency of which my child and I hereby expressly acknowledge, my child and I hereby release, waive, discharge and covenant not to sue the Urban Ecology Center, or their heirs, assigns, personal representatives, estate, agents and employees (hereinafter referred to as “Releasees”) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or relating to any loss, damage or injury, including death, that may be sustained by my child, or to any property belonging to my child, whether caused by the negligence of the Releasees, or otherwise, while participating in the summer camp.

My child and I are fully aware of risks and hazards connected with participating in the summer camp, and my child and I are fully aware that there may be risks and hazards unknown to me, or my child, connected with participating in the summer camp, and my child and I hereby elect to voluntarily have my child participate in the summer camp, and to engage in activities knowing that conditions may be hazardous, or may become hazardous or dangerous to my child and my child’s personal property. My child and I voluntarily assume full responsibility for any risks of loss, property damage or personal injury, including death, that may be sustained by my child, or any loss or damage to property owned by my child, as a result of my child participating in the summer camp, whether caused by the negligence of Releasees or otherwise. My child and I further hereby agree to indemnify and save and hold harmless the Releasees and each of them, from any loss, liability, damage or costs they may incur due to my child participating in the summer camp, whether caused by the negligence of any or all of the Releasees, or otherwise.

It is my child’s and my own express intent that this Release shall bind the members of my family, my child’s family, and our heirs, successors, assigns, administrators, executors and personal representatives, and shall be deemed as a Release, Waiver, Discharge and Covenant Not to Sue the above named Releasees.

I give my permission for my child to participate in these physically and emotionally demanding activities.

I understand the Urban Ecology Center reserves the right to send my child home early due to illness, accident or behavioral problems. If the Camp Director decides to send my child home early, I understand I will be responsible to pick up my child from camp.

In signing this Urban Ecology Center Summer Camp Consent Form and Release, I and my child acknowledge and represent that:

We have read the foregoing paragraphs of this Urban Ecology Center Summer Camp Consent Form and Release, understand it, agree to uphold it and sign it voluntarily as our own free act and deed;
No oral representation, statements or inducements, apart from the foregoing written agreement, have been made; and
We execute this Release for full, adequate and complete consideration fully intending to be bound by same.

By entering my name, I certify I have thoroughly read the Liability Waiver and Release above. I understand and agree to abide by the policies stated therein.*

Photo/Video Release

I grant permission for images of my child, through pictures, videos and likenesses to be used for educational and promotional purposes by the Urban Ecology Center. Likenesses may be published in print, on Urban Ecology Center website, Urban Ecology Center social media sites. I hereby waive my rights to approve finished products that may be used and of compensation or ownership thereto.*

Parent Certification

I certify that I am the parent or guardian of the child indicated above and that my consent and permission granted are valid for the full duration of the camp(s) for which I am registering my child.

The information provided for my child's participation in Urban Ecology Center programming is correct and complete, to my knowledge.

E-signature required. Please type your full name (First, Middle, Last)

Full name*

Today's date*

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Camper Profile and Health Form