Camper Information and Waivers 2021 Cylburn Arboretum Nature Camps
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Camper Information and Waivers 2021
Cylburn Arboretum Nature Camps
Welcome to Cylburn Arboretum Nature Camp, Summer 2021. Please read through and complete the
registration forms carefully, one packet per child enrolled.
Please scan and email your complete packet(s) to naturecamp@cylburn.org. You may also mail
completed forms to 4915 Greenspring Avenue Baltimore, MD 21209. Deadline for returning your packet is
May 1, 2021.
Cancellation Policy Reminder
If you must cancel your reservation, the following policy applies, if you cancel by:
• May 1, 75% of your registration will be refunded
• June 1, 50% of your registration will be refunded
• After June 1, 25% of your registration will be refunded
I have read and understand the Registration Cancellation Policy. _________________________________
Camp Session Dates:
June 21 - July 2
July 12 - 23
1Camper Information
Child’s name: ________________________________________________________________________
Birth date: _______________ Gender: Male Female Other Height: ________ Weight: _______
Home address: ________________________________________________________________
City: ______________________________ State: _______________ Zip Code: ___________
School: ______________________________________________________________________
Does your child have special needs? Yes No If yes, please explain: _______________________
_______________________________________________________________________________________
Does your child participate in an IEP (Individual Education Program)? Yes No If yes, please
explain: _________________________________________________________________________________
Camp Shirt Size (please choose one):
Child: Adult:
XS S M L XS S M L
Emergency Contact Information
Primary Contact: _______________________________________________Relationship:________________
E-Mail Address: ___________________________________________
Phone: home______________ business____________ cell__________________ other________________
Home address: ________________________________________________________________
City: ______________________________ State: _______________ Zip Code: ___________
Secondary Contact : _______________________________________ Relationship: _____________________
E-Mail Address: ________________________________
Phone: home______________ business____________ cell__________________ other________________
Contact address: _____________________________________________________________
City: ______________________________ State: _______________ Zip Code: ___________
2Parental Signature
(Please initial each section and sign in the space provided.)
Camper Name: _______________________________________________________________
Behavior and Cancellation Agreement (Initial_________ )
I agree that my camper will cooperate and accept camp standards of behavior. Failure in this area may result
in camp discipline or dismissal. The Camp Director and / or Camp Administrator have the right to dismiss any
child for behavioral problems. I agree and understand that in all cases of dismissal, homesickness, or
voluntary withdrawal, there will be no refund of any fees. Once accepted, all cancellations must be in writing
and submitted to the camp office. Please refer to the Cancellation Policy on the first page of this packet.
Cylburn Arboretum Friends STANDARD RELEASE STATEMENT (Initial __________)
I hereby release the Board of Directors of the Cylburn Arboretum Friends, employees and volunteers from
all claims or actions of every nature and description.
Baltimore City STANDARD RELEASE STATEMENT (Initial__________)
I hereby release the Mayor and City Council of Baltimore, its elected and appointed officials, employees
and volunteers from all claims or actions of every nature and description.
Emergency Transportation Agreement and Release (Initial __________)
In the event of a medical condition or emergency requiring transportation of the above named Camper to
the Sinai Hospital emergency room but not requiring a call to 911 or ambulance, I agree and
acknowledge that transportation may be provided by Staff of Cylburn Arboretum Nature Camp by private
car (driven by a properly licensed driver, with seat belts used by all passengers), or any other reasonably
prudent and available means to secure immediate medical attention. I hereby agree and acknowledge
that such means of transportation may be used, and consent to its use.
Application of Sunscreen (Initial __________)
Is Cylburn staff allowed to assist camper in application of sunscreen? YES NO
Application of Bug Spray (Initial __________)
Is Cylburn staff allowed to assist camper in application of bug spray? YES NO
Permission to Publish Images of My Child (Initial __________) YES NO
IF YES, I do grant Cylburn permission to publish images of my child. The child will never be identified by
name without additional written permission from parent or guardian.
Parent / Guardian signature____________________________________ Date: __________________
Rules for acceptance and participation in the programs at Cylburn Arboretum are the same for everyone, regardless
of ethnic background, religion, or gender.
3Departure/Pick-Up
Cylburn Arboretum Nature Camp MINOR CAMPER RELEASE POLICY
No camper will be allowed to leave camp with someone other than his/her custodial parent/guardian unless
written permission is granted (below) by the custodial parent/guardian. (Special permission may be granted
by custodial parent/ guardian in writing no later than the morning of the day the child is to be released to
another person.) We will release campers to either parent unless directed by court order to do otherwise.
Adults dropping off and picking up campers will be asked to initial our drop-off/ pick-up forms before
removing a camper from our premises.
My camper, ________________________________________ can be released to the following people:
Custodial Parent/ Guardian: _____________________________________________________
Second Custodial Parent/ Guardian: _______________________________________________
Other guardian(s): _____________________________________________________________
_____________________________________________________________
_____________________________________________________________
For a camper to walk or bike home alone, you must give WRITTEN PERMISSION below:
My Child ____________________________________
HAS MY PERMISSION __________ (initials of custodial parent / guardian) to walk and/ or
bike to and from camp each day alone.
Does not have my permission __________ (initials of custodial parent / guardian) to walk
and/ or bike to and from camp each day alone.
My signature below means I understand the Cylburn Arboretum Friends minor release policy and have
indicated above the adults to whom my child may be released.
Parent/Guardian signature ___________________________________ Date _____________________
4Medical Disclosure
Campers must be up to date on all immunizations, see www.edcp.org (immunization).
Per the regulations of the Maryland Department of Health, please provide copy of the Maryland
Department of Health Immunization Certificate with camper’s immunization record showing that
their immunizations are up-to-date. This form must be signed by a state licensed physician.
Children will not be able to attend camp unless their immunizations are up-to-date.
I have provided a signed copy of the Maryland Department of Health Immunization Certificate.
Provide month, date, and year of camper’s last tetanus (or DPT) shot: _________________________
Camper's Physician ______________________________________ and Phone number ________________
My child,____________________________________ is subject to:
Asthma controlled by medication? YES NO Is an inhaler required? YES NO
Indoor/Outdoor Environmental allergies controlled by medication? YES NO
Emergency medication required? YES NO
Please specify allergens:
Food allergies—controlled by medication? YES NO
Emergency medication required [i.e., EPI pen, etc.]? YES NO
Please specify allergens: __________________________________________________
Allergies to medications? YES NO
Please specify allergies to medications: _______________________________________________
List other illness of disease that requires special treatment or precautionary care:
_______________________________________________________________________________
No health issues that will affect his/her participation in camp activities.
Youth camp participation was discussed with the camper’s healthcare provider including
considerations related to risk of COVID-19.
My signature below means I have read and understood the Medical policies and I attest that all
information provided on this and any attached forms is true and accurate.
Parent/Guardian signature ________________________________________ Date ________________
Rules for acceptance and participation in the programs at Cylburn Arboretum are the same for everyone, regardless
of ethnic background, religion, or gender.
5PLEASE NOTE: Counselors will be trained in CPR and First Aid. If your child requires any medical treatment
that exceeds the basic First Aid that can be administered by our counselors, we will call an ambulance to
ensure your child’s safety and well-being. Our health supervisor is on staff at Sinai Hospital.
Any medication that is required for your child must be able to be self-administered or administered
by a parent or guardian.
Questions about this application? Please contact naturecamp@cylburn.org. Thank you.
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