Prairies to Peaks Iron Horse Rail Summer Camp REGISTRATION AND HEALTH FORM

Transcription

1 Prairies to Peaks Iron Horse Rail Summer Camp REGISTRATION AND HEALTH FORM Section 1 Basic Contact Information Campers Name: _ Nickname:_ Birth date / / Gender: Male Female T-shirt size: Adult / Youth Camper Lives with: Mother & Father Mother Father Grandparent Other Street Address: City Zip Code: Father/Mother/Guardian Name: Day : Night : Day is: Home Work Cell Night is: Home Work Cell Additional Emergency Contact (In case we can't reach YOU) Name: Relationship Day : Night : Day is: Home Work Cell Night is: Home Work Cell Doctor Contact Information (only if child is currently under treatment) Family Physician Name Dentist/Orthodontist Name If you will be traveling during the camper's stay at Prairies to Peaks Iron Horse Rail Summer Camp. Please inform us in writing of any travel plans. Attach phone numbers, local relative names and numbers, and/or any other information that would assist us in contacting you in case of an emergency.

2 Section 2 Insurance Information Insurance Carrier Group or Policy # Policy Holder's Name: Relationship to participant: We strive to make Prairies to Peaks Iron Horse Rail Summer Camp a safe place for our campers. One way that we do that is by having you complete a health history for your child so that we may be better prepared in the event of an emergency. The health form is kept confidential and will only be used if needed by emergency medical personnel. Every camper NEEDS a completed health form to participate in any camp programs. Please fill out this form as completely as possible. Campers are not singled out, made to feel embarrassed or treated differently because of information gathered from the health form. Rather, the more we know ahead of time, the easier it is to help the child have a successful experience at camp. Thank you! Section 3a Medications: Will the camper be taking medications while at camp? Yes No (medications include prescription, over-the counter, vitamins, inhalers, etc.) If Child will be taking NO medication during their time at Prairies to Peaks then please skip to Section 3b Restrictions and Instructions If camper will be taking medications while at camp, please list all (prescription and non-prescription). Include the medication name, prescribing physician, physicians' phone number, and the dosage instructions. W h e n t h e c a m p e r checks-in at camp, please have them provide all medications in their original packaging that identifies the prescribing physician (if prescription drug), the name of the medication, the dosage, and frequency of administration. Medication _Dosage Taken: Breakfast Lunch Dinner Bed Time _

3 Section 3b Restrictions and Instructions (if none please skip to Section 4) Special Instructions or Considerations for Minor Illness Unless specific instructions are provided camp health care staff will treat minor illnesses (headache, insect bite, etc.) with over the counter medications. If illness persists, parents will be notified. Special Dietary Needs Physical Activities to be Limited or Restricted while at Camp Anything else you think we should know Section 4 Allergies Camper does not have any Allergies (proceed to Section 5) Camper is allergic or has an extreme reaction to: 1.Pollen and Dust 2.Poison Ivy/Oak 3.Bee Stings 4.Insect Stings 5.Food 6.Penicillin 7.Other Drugs 8.Other List Allergy #'s. Describe reaction and treatment Section 5 Immunizations Camper must be immunized according to DHEC standards. Are immunizations required for public school up to date? Yes No Section 6 Health History Please know that we value your privacy. Health History information is available only to the camp s official staff. Only after a conversation with you and with your permission will any of this information be given to your child's counselor. We request this information in order to give your child and all the other children at camp a more successful and safe experience. The more information you provide, the better we can do our job. Thanks! Has the camper had a history of or is prone to any of the following (Please check all that apply): 1.Recent injury, illness, or infectious disease 2.Chronic or recurring illness 3.Asthma 4.Homesickness 5.History of Bedwetting 6.Sleepwalks 7.Nightmares/Night Terrors 8.Frequent Ear Infections 9.Seizure Disorder or Convulsions 10.H.I.V 11.Hepatitis 12.Heart Defect/Disease 13.Hypertension 14.Bleeding/Clotting Disorders 15.Diabetes 16.Mononucleosis (in last 12 months) 17.Joint Problems (knees, ankles) 18.Fractures (2 months) 19.Frequent Headaches or Migraines 20.Head Injury 21.Psychiatric Disorder or Treatment 22.Eating Disorder 23.Diarrhea or Constipation 24.Frequent Stomachaches 25.Needs to wear glasses or contacts 26.Been hospitalized recently 27.Wears a Medic Alert ID 28.Other Please list the number and provide explanation for any checked items

4 Section 7 Medical and Liability Releases MEDICAL RELEASE: This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted. In the event I cannot be reached in emergency, I hereby give permission to the physician selected by Prairies to Peaks Iron Horse Rail Summer Camp to hospitalize, secure proper treatment for, and to order injection and or anesthesia and/or surgery for the camper named above. I understand that Prairies to Peaks Iron Horse Rail Summer does not provide medical insurance or reimbursement for medical fees or prescriptions and that I am responsible for any and all such fees and charges arising from illness or injury that may occur. This completed form may be copied for transportation record. LIABILITY RELEASE: The undersigned, for himself or herself and personal representatives, assigns, heirs and next of kin (herein referred to as releasers), hereby released, waives, discharges and covenants not to sue Prairies to Peaks Iron Horse Rail Summer, its agents, servants and employees (herein referred to as releases) from negligence of releasers or otherwise while participating in activities associated with Camp. The undersigned is full aware of the inherent hazards and hereby elects to participate voluntarily and assume all risks of loss, damage or injury that may be sustained by him or her. OFF CAMP RELEASE: The previously named camper has my permission to be transported and participate in outings and field trips conducted off the camp s grounds. It is understood that these outings are fully supervised by qualified camp staff. The undersigned has read and voluntarily signs this Medical Release, Waiver of All Liability and Assumption of Risk: Agreement and off Camp Release: I agree to the above: Signature of Parent or Guardian Date I understand that my signature above is confirmation of a Medical and Liability Release! Section 8 - Authorization Regarding my child: (Camper s Full Name) The information provided on this form is accurate to the best of my knowledge. I have indicated any special health conditions, including required medication and activity limitations which should be known to the camp staff and medical personnel. My child may participate in ALL camp activities. I realize that Prairies to Peaks Iron Horse Rail Summer Camp will make every effort to conduct safe programs and events, but there is always some risk involved in any activities. I accept these risks as part of my child s participation, and hereby waive any rights that I, or said minor, may have to sue Prairies to Peaks Rail Iron Horse Rail Summer Camp or any of their employees, as a result of any and all injuries, damages, or losses sustained by the mentioned minor child while participating in the standard camp program. Conduct: As a private, non-profit organization, Prairies to Peaks Iron Horse Rail Summer Camp expects a high standard of conduct and dress. Prairies to Peaks Iron Horse Rail Summer Camp reserves the right to ask campers to change improper clothing, and to dismiss anyone for misconduct- tobacco, drugs, alcohol, profanity, disrespect, bullying, questionable remarks and gestures will not be tolerated. Photos: I give permission to Prairies to Peaks Iron Horse Rail Summer Camp to use photographs and/or video of my child for promotional purposes.

5 Insurance, Treatment, and Medicine: I/we understand my medical insurance will be considered primary in case of accident or injury. In addition, by signing below, I authorize, Prairies to Peaks Iron Horse Summer Camp officials, after an attempt to contact me in a timely manner, to act in place of parents/guardians to secure proper medical treatment, hospitalizations, injections, medicines, transfusions, and/or surgery in the event of an emergency. I also agree for the camper to be given the medicines listed in Section 3 of this form in the manner they are prescribed and/or directed. I also agree for the camper to receive over-the-counter medications (i.e. Tylenol, Pepto Bismol, etc.) according to label directions, and to receive minor first aid from the Prairies to Peaks Staff. I agree to the above: Signature of Parent or Guardian Date I understand that all camper fees are paid for by a Scholarship; w i t h t h e n o t e d e x c e p t i o n t h a t t h e c a m p e r s p a r e n t / g u a r d i a n i s r e s p o n s i b l e f o r t h e e x p e n s e o f t r a v e l t o a n d f r o m t h e c a m p l o c a t i o n, a n d t h a t c a m p r e g i s t r a t i o n s a r e a c c e p t e d o n a f i r s t c o m e f i r s t s e r v e d b a s i s. I a l s o u n d e r s t a n d t h e r e a r e n o Registration Fees and that my signature above is confirmation of and my request for acceptance of Registration for my child at Prairies to Peaks Iron Horse Rail summer Camp. Please submit completed form by mail or fax to: Prairies to Peaks Iron Horse Rail Summer Camp c/o W. K. (Ken) Naylor Suite rd Avenue North Billings, Montana : Fax: or electronically via to: (naylormt@midrivers.com)