Clear Creek Student Health Information Clear Creek Student Health Information Camp attendance and health info for students attending clear creek. Please make sure to have your student's Alpine Student Id before filling out this form. If you do not have it please contact your child's school. Student ID*Student Name* First Last Select camp week student is registered to attend*Select WeekJune 4-8June 11-15June 18-22June 25-29July 2-6July 9-13July 16-20July 23-27July 30 - August 3August 6-10Parent or Legal Guardian Name (Primary Emergency Contact)* First Last Parent email* Enter Email Confirm Email Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone (emergency/important communication)*Emergency Contact and Medical InformationAdditional Emergency Contact*Contact NameContact PhoneContact Relationship Does your child have a health condition that would limit his/her activity at camp?*YesNoIf yes, please describe health condition*Does your child have required medication(s) you will be sending with him/her to camp?*YesNoIf yes, list medications by name, dosage and directions*Does your child have food allergies or other special dietary requirements?*YesNoIf yes, please describe food allergy or special dietary requirements*May the camp staff give Acetaminophen (Tylenol) 325 mg tablet to your child if needed?*YesNoMay the camp staff give Ibuprofen 200 mg tablet to your child if needed?*YesNoMay the camp staff give Diphenhydramine HCL (Benadryl) 25 mg tablet to your child if needed?*YesNoMay the camp give calcium carbonate (Pepto Bismol) 400mg to your child if needed?*YesNoMay the camp staff treat minor wounds with Neosporin antibiotic ointment for your child if needed?*YesNoBy selecting "I agree," I attest that I am the custodial parent or legal guardian of the student above and the information is true and correct. I attest that the student's legal residence is within the boundaries of Alpine School District. I agree that the Clear Creek staff may treat my child according to the answers and instructions that have been provided in this form.*I agreeBy selecting “I agree,” I understand that there will be a $25 fee for cancellations requested more than 48 hours in advance of the 7:00 A.M. camp check-in period on Monday morning. I also understand that there will be no refund for voluntary withdrawal during camp or during the 48 hours preceding the camp check-in period.*I agree This iframe contains the logic required to handle Ajax powered Gravity Forms.