Monett Summer Camp Application 2025

Participant Name(Required)
MM slash DD slash YYYY
Address(Required)

*If homeschooled, please specify
Service Coordinator Name
Parent or Guardian Name(Required)
Parent or Guardian Address (If different from participant)
Email(Required)

Emergency Contacts (Must list two)

Emergency Contact #1(Required)
Emergency Contact #2(Required)
Emergency Contact #3

Physician

Primary Physican(Required)
Address

Health History

Medication Taken?(Required)
If you answered YES, the following MUST be completed. In case of a medical emergency, we need to know what medication(s) are taken, even if medication is NOT taken during recreation program hours.
Please list ALL medications including: name of medications, dosage, time to be given, and possible side effects.
Ashma(Required)
Does the individual require an inhaler?(Required)
Any Allergies?(Required)
Does the individual/you carry an EpiPen?(Required)
Diabetic?(Required)
Feeding Information
Deaf/Hearing Impaired?(Required)
Interpreter Needed?
Nonverbal?(Required)
Physical Disability?(Required)
Wheelchair/Walker/Cane/Crutch?(Required)
If YES, which type?
Physical Limitations?(Required)
Safety Harness or Gait Belt Required?(Required)
If answered YES to safety harness or gait belt, when is it utilized?
Heart Condition?(Required)
Seizures?(Required)
MM slash DD slash YYYY
Exposure to Sun?(Required)
Swim Experience?(Required)
Does the individual need a lifejacket?(Required)
Toileting Information(Required)

Parent/Guardian Signature(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
*If homeschooled, please specify
MM slash DD slash YYYY
The Arc of the Ozarks Publicity Release(Required)
I, (parent/guardian) hereby authorize The Arc of the Ozarks to include (participant’s) name and/or picture in the following (click all that apply):
MM slash DD slash YYYY