11 Park Lake Road
Sparta, NJ 07871
Phone: 973-383-2213
Fax: 973-383-5915
Summer KEEP Registration
Date of Application: *

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Start Date: *

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Child's Name: *

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Child's Age *

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Date of Birth *
/ /
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Child's Gender: *

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Street: *

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City: *

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Zip Code: *

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Phone Number (i.e., 1234567890): *

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Preferred Email Address: *

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Mother's Information

Relationship to Child *

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Mother's Name *

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Home Number (i.e., 1234567890): *

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Cell Number (i.e., 1234567890): *

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Home Address (complete): *

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Employer's Name:

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Employer's Address:

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Employer's Phone (i.e., 1234567890):

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Work Email Address:

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Father's Information

Relationship to Child *

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Father's Name *

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Home Number (i.e., 1234567890): *

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Cell Number (i.e., 1234567890): *

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Home Address (complete): *

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Employer's Name:

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Employer's Address:

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Employer's Phone (i.e., 1234567890):

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Work Email Address:

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Are you or your spouse currently enlisted in the Armed Forces? *

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Emergency Contacts: Persons authorized to pick up child in case of emergency if neither parent is available Please provide at least two LOCAL contacts. (persons must be at least 18 years of age)

Primary Contact Name: *

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Primary Contact Relationship: *

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Primary Contact Address: *

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Primary Contact Phone Number (i.e., 1234567890): *

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Primary Contact Cell Number (i.e., 1234567890): *

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Secondary Contact Name: *

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Secondary Contact Relationship: *

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Secondary Contact Address: *

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Secondary Contact Phone Number (i.e., 1234567890): *

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Secondary Contact Cell Number (i.e., 1234567890): *

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Medical Information

Does the child have allergies? *

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Allergy List

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Is the child on medications? *

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Medication List

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Does the child have special needs? *

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Special Needs List

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Physician Name *

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Physician Address (complete) *

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Physician Phone Number (i.e., 1234567890): *

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Releases and Signatures


PLEASE READ THE FOLLOWING:

I give permission for my child to remain in the care of the Summer K.E.E.P. Program. My child is in good mental and physical health, has had the necessary childhood immunizations and, to the best of my knowledge, is free of any contagious diseases. I agree to submit the enclosed Health History.

I agree that emergency treatment and/or care can be provided by the Summer K.E.E.P. counselor in the event that my child suffers a minor injury. I also agree that in the event of serious injury the emergency squad will transport my child to the nearest area hospital. In the absence of a family member or emergency names given above, I give my permission for the Director of the Summer K.E.E.P. program and/or administration of K.E.E.P., Inc. to make a decision concerning my child’s care on the advice of the attending physician.

K.E.E.P., INC. ACCEPTS PARTICIPANTS WITHOUT REGARD TO RACE, COLOR, CREED OR NATIONAL ORIGIN. ACCEPTANCE IS FIRST COME, FIRST SERVED, THEN WAITING LIST. K.E.E.P., INC. RESERVES THE RIGHT TO REFUSE AN APPLICANT OR TO DISMISS A PARTICIPANT AS DEEMED NECESSARY.

WE (I) AGREE THAT IN CASE OF DISMISSAL FOR CAUSE OR OF VOLUNTARY DEPARTURE, THERE WILL BE NO REFUND OF SUMMER K.E.E.P. FEES FOR THE TIME RESERVED. I HAVE READ AND CONFIRMED ALL INFORMATION CONTAINED IN THIS APPLICATION. I HAVE READ AND ACCEPT THE TERMS OF THE ENCLOSED PARENTS INFORMATION GUIDE AND FINANCIAL POLICIES. ALL PICTURES TAKEN AT SUMMER K.E.E.P. OF ACTIVITIES, GROUPS, ETC. MAY BE USED IN PROMOTION OF K.E.E.P., INC. THIS APPLICATION HAS MY APPROVAL AND CONSENT.



Agreement Of Contract Terms *

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The following voluntary information will help us determine and demonstrate to County, State and Federal agencies the areas in need of assistance. All information will be kept confidential. Please check your annual income below:

Income

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Race

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We have a variety of resources from which we can offer scholarships and financial assistance to those in need. I am in need of financial assistance.

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If “Yes”, contact K.E.E.P., Inc. at (973) 383-2213 for more information.


K.E.E.P. Financial Contract

I understand that all camp payments are due to the K.E.E.P., Inc. main office prior to or no later than the time of drop off of my child. Any daily account balance not paid in full by the start of programming will be charged $40.00 per day to the credit/debit card provided in the financial contract. Should the credit/debit card be declined, services will be immediately terminated and a $50 penalty added to the amount due. All outstanding balances must be paid in full for reinstatement.

K.E.E.P., Inc. invoices by email. Your account can easily and securely be paid by clicking on the unique link on the bottom left of the invoice. Forms of payment accepted online are Bank Account and Visa and Master Card. Payments may also be made by cash, check, credit/debit card or money order in the Business Office. If payment is made by credit/debit card in the Business Office, a 2% Surcharge will be added to the total invoice amount.

The credit/debit card information below is to be used for default purposes (which may include but are not limited to: tuition, late pick up fees, K.E.E.P. supplied lunch, etc.) and will be kept secure and not shared with the public or any other agency. This section MUST be completed by all clients.

By completing this form, you authorize K.E.E.P., Inc. to deliver future invoices to you via e-mail to the address provided below. This address must match the e-mail currently on file. To update the e-mail address on file, please cal 973-383-2213. Sending an e-mail to your e-mail address on record, with no bounce-back, is conclusive proof of simultaneous actual receipt by you.

Initial Here *

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Credit Card
A credit/debit card number MUST be provided by all clients for default purposes as outlined within the financial contract.

Credit Card *

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Card Number *

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3 or 4 Digit Verification Code on back *

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Expiration Date *

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Billing Address on Card:

Street: *

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City: *

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State: *

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Zip Code: *

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Signature(s) Of Person(s) Responsible for Payment:

Signature *

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Date: *

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Signature

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Date:

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I have read the above Financial Contract, as well as the K.E.E.P., Inc. Financial Policies and Additional Polices as outlined in the K.E.E.P., Inc. Handbook and agree to and accept all of the terms outlined therein.
Agreeing to and signing this electronic document is equivalent to signing a printed form and carries with it all responsibilities/penalties as such.

Signature *

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Date: *

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Number of Dependent Children *

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ENROLLMENT FORM

For each designated week, please carefully check the days your child will attend.

*

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WEEK OF JUNE 12 – JUNE 16

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WEEK OF JUNE 19 – JUNE 23

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WEEK OF JUNE 26 – JUNE 30

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WEEK OF JULY 3 – JULY 7

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WEEK OF JULY 10 – JULY 14

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WEEK OF JULY 17 – JULY 21

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WEEK OF JULY 24 – JULY 28

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WEEK OF JULY 31 – AUGUST 4

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WEEK OF AUGUST 7 – AUGUST 11

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WEEK OF AUGUST 14 – AUGUST 18

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WEEK OF AUGUST 21 – AUGUST 25

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WEEK OF AUGUST 28 – SEPTEMBER 1

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* Standard Day Schedule is 7am-6pm. Extended Day is 6:30am-6:30pm. (Additional charge applies)

The days marked above will be considered temporarily reserved for your child(ren). Please be advised that no spot is definitely reserved until full payment is either made or guaranteed. This form helps us to plan appropriately and we would be most appreciative of notification for any known changes. Applicable K.E.E.P. policies will be enforced.

Signature
*

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SUMMER KEEP HEALTH HISTORY AND MEDICAL RELEASE FORM


Health History
(Give approximate dates) allergies/reactions/problems:

Ear Infections

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Ear Infections dates/allergies/reactions/problems:

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Asthma

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Asthma dates/allergies/reactions/problems:

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Bee Stings

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Bee Stings dates/allergies/reactions/problems:

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Heart Defects

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Heart Defects dates/allergies/reactions/problems:

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Hay Fever

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Hay Fever dates/allergies/reactions/problems:

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Penicillin

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Penicillin dates/allergies/reactions/problems:

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Convulsions

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Convulsions dates/allergies/reactions/problems:

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Insect Bites

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Insect Bites dates/allergies/reactions/problems:

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Diabetes

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Diabetes dates/allergies/reactions/problems:

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Poison Ivy

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Poison Ivy dates/allergies/reactions/problems:

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Other

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Other dates/allergies/reactions/problems:

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Operations and/or serious injuries (list and give dates)

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Chronic or recurring illness:

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Other problems or details for above history:

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Name & Phone Number of Dentist:

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Name & Phone Number of Physician:

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Additional Comments

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Date of last medical examination: *

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Date of last Tetanus Shot *

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Medical/Hospital Insurance Carrier:

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Policy/Group#

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Any specific activities to be restricted? (Please list and give details why;)

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Any mental or physical conditions the Summer K.E.E.P. staff should be made aware of?

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Please list any medications she/he is taking:

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What medications will be sent to be taken at camp?

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Does she/he wear glasses? (please check all that apply)

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Other

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Special Diet Conditions

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FOR FEMALES: (please check all that apply)

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Special Considerations

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IMMUNIZATION HISTORY
THIS INFORMATION MUST BE PROVIDED IN ORDER TO ENROLL YOUR CHILD IN SUMMER K.E.E.P. A COPY OF THE DOCTOR’S RECORDS IS ACCEPTABLE.


Diptheria, Pertusis, Tetanus: DPT, or Tetanus, Diphtheria, TD or Tetanus

DATE OF BASIC IMMUNIZATION *

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DATE OF LAST BOOSTER *

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DATE OF DISEASE

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Oral Polio (Sabin): TOPV

DATE OF BASIC IMMUNIZATION *

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DATE OF LAST BOOSTER *

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DATE OF DISEASE

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Injectable Polio (Salk)

DATE OF BASIC IMMUNIZATION *

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DATE OF LAST BOOSTER *

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DATE OF DISEASE

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Measles (hard, red, Rubeola)

DATE OF BASIC IMMUNIZATION *

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DATE OF LAST BOOSTER *

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DATE OF DISEASE

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Mumps

DATE OF BASIC IMMUNIZATION *

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DATE OF LAST BOOSTER *

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DATE OF DISEASE

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Rubella (German, 3 day)

DATE OF BASIC IMMUNIZATION *

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DATE OF LAST BOOSTER *

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DATE OF DISEASE

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Hib

DATE OF BASIC IMMUNIZATION *

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DATE OF LAST BOOSTER *

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DATE OF DISEASE

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Hepatitis B

DATE OF BASIC IMMUNIZATION *

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DATE OF LAST BOOSTER *

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DATE OF DISEASE

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Chicken Pox

DATE OF BASIC IMMUNIZATION *

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DATE OF LAST BOOSTER *

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DATE OF DISEASE

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Most Recent Tuberculin Test

DATE OF TEST *

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Tuberculin Results *

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Photo Release All pictures taken at K.E.E.P., Inc. of activities, groups, etc. may be used in promotion of K.E.E.P., Inc. *

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PARENT/GUARDIAN RELEASE: To the best of my knowledge, this history is correct and complete. I know of no reason to restrict the camper/staff activity (other than listed), and give my permission for participation in all activities (except as noted). In the event that I cannot be reached in an emergency, I hereby give my permission to the physician selected by the Summer K.E.E.P. director or her/his designee to secure proper treatment, including, but not limited to, hospitalization, for the person named in this form.
Signature

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Date *

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SUMMER K.E.E.P. CAMP FIELD TRIP PERMISSION
I give above named child permission to walk to White Lake Beach, Sparta, and to participate in activities, including swimming, each day that Summer K.E.EP. provides camp activities at White Lake.
Signature

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Date

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Submit Verification Code *
Submit Verification Code
  Refresh
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