Camp Information Mt. Hood Meadows Camper Information Camper's Name(Required) First Last Which camp is your child signed up for?(Required) Explorer Camp - July 11-14 Explorer Camp - July 18-21 Adventure Camp - July 25-28 Adventure Camp - August 1-4 Adventure Camp - August 8-11 Mountain Bike Camp - August 15-18 Mountain Bike Camp - August 22-25 Child's Date of Birth(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Emergency Contact Name(Required) First Last Emergency Contact Phone Number(Required)Email TransportationPlease select your child's pick up location(Required) Portland - Lloyd Center *Departs 7:30AM, Returns 5:30PM Troutdale - Dairy Queen *Departs 8:00AM, Returns 5:00PM Hood River - China Gorge *Departs 8:50AM, Returns 4:15PM They don't need tranpsortation. We will be driving up to Mt. Hood Meadows. Medical InformationDoes your child have any Food or Environmental Allergies?(Required) Yes No Please list specific allergies(Required)Does your child use an EPIPEN?(Required)If yes, the child must carry it at all times. Yes No Will your child need to take any medications during their time at camp?(Required) Yes No Please tell us which medications and their instructions(Required)List of Medications the Child is TakingAllergies or Chronic Problems (Ex: asthma, allergy to penicillin, heat murmur, diabetes)Any additional Medical Information we need to know?Date of Last Tetanus Shot Name of Child's Doctor First Last Doctor's Phone NumberName of Child's Dentist First Last Dentist's Phone NumberHealth Insurance CompanyPolicy/Group NumberI herby authorize the Emergency Department of Providence Hood River Memorial Hospital or other acute care facility to administer such examinations, diagnostic and medical treatment or surgery as may be necessary or advisable for the health and well-being of my child. For this reason it's important to have health information on each of your children readily available for relatives, babysitter, school personnel and other who may be present when an accident occurs. Providence Hood River Memorial Hospital will keep this form on file and a copy will be retained at your child's school. Our Emergency Department staff will make every effort to reach you if your child is brought in for treatment. With this information and authorization readily available, your child will be able to receive proper treatment as efficiently as possible. Providence Hood River Memorial Hospital - (541)386-3911 or 1-(800)955-3911 (Gorge Only) Ambulance Service - 911 Poison Control - 1-(800)222-1222Signature(Required)Authorization for medical and/or surgical treatment and hospital service is valid for one (1) year from date of signature Your NameYour NameYour NameYour Name