Camp CF Participant Information Form

Cedar Falls Recreation Camp CF Participant Information
Participant Photo*
Site*
Participant Name*

First NameLast Name
Male or Female*
Birth Date*

MonthDayYear
Date
Parent/Guardian Name 1*

First NameLast Name
Phone Number 1*
Please enter a valid phone number.
Email*
example@example.com
Parent/Guardian Name 2

First NameLast Name
Phone Number 2
Please enter a valid phone number.
Email
example@example.com
Additional Pick Up Persons/Emergency Contacts

NamePhone Number
NamePhone Number
NamePhone Number
Signature*

Clear

LIMITED POWER OF ATTORNEY FOR EMERGENCY MEDICAL CARE AUTHORIZATION
I, the undersigned, being the parent or legal guardian of said minor child, know that I may not be available to authorize medical, dental, surgical care and hospitalization for said minor child. In the event of injury, program supervisors shall administer basic first aid, and shall summon emergency services via 911. Supervisors are not trained to provide detailed medical care, and shall not, without prior agreement, provide medications. All costs of emergency care are the responsibility of the participant/participant’s legal guardian(s). NO INSURANCE IS PROVIDED BY THE CITY FOR INJURY TO PARTICIPANTS. All claims for reimbursement of medical care costs, including emergency transportation, are hereby waived.

PARTICIPANT RELEASE TERMS I recognize and understand the activity and give my permission and consent to this participation/membership. I recognize that proper care of equipment, facilities, and adequate supervision will be provided, but that inherent in these activities is a degree of assumption of risk. I do hereby absolve, release and agree to hold harmless the City of Cedar Falls, sponsors, leaders, agents, and volunteers from liability claims in case of accidents.

I HAVE READ THIS DOCUMENT CAREFULLY AND UNDERSTAND IT. I AM SIGNING THIS FREELY AND WITHOUT RESERVATION OR CONDITION. (IF YOU HAVE ANY QUESTIONS ABOUT THIS DOCUMENT DO NOT SIGN IT. CONTACT AN ATTORNEY TO ASSIST YOU.)
Health Insurance Carrier *
Policy Number *
Signature*

Clear
Date *
H:WorkRisk ManagementRELEASESRevised 2010Release and Medical Authorization.Rec Center Programs.2010.doc

MEDICAL CONSENT FORM AND HEALTH CARE INFORMATION
Child's Name*

First NameLast Name
Child's Family Doctor*

First NameLast Name
Doctor Phone Number*
Please enter a valid phone number.
Child's Family Dentist*

First NameLast Name
Dentist Phone Number*
Please enter a valid phone number.
Date of last Tetanus*

MonthDayYear
Date
Are all immunizations current?*
Allergies: (please include drug, food, pets)
Present Medication: (A medication release form must be completed for all medications distributed at Camp CF, including over the counter items)
Please list significant illnesses and surgeries thechild has had: (give age and dates)
Does your child have any physical condition ordisability, which our staff should be aware of?Would this restrict his/her activity? Pleaseexplain condition and accommodation required:
Is this child subject to any condition, whichlimits classroom or physical activities?
Is this child subject to any mental or physical condition for which he/she should remain under periodic medical observation? For behavior conditions, please explain approach used at home/school to correct:
Other information staff should be aware of?
H:WorkRisk ManagementRELEASESRevised 2010Release and Medical Authorization.Rec Center Programs.2010.doc

CONSENT FOR GIVING MEDICATIONS:

Complete this portion of the form only if your child will be taking medication during program hours.
Medication
Amount
Time To Be Given
Dates To Be Given
Medication
Amount
Time To Be Given
Dates To Be Given
I (Parent/Guardian) blankgive consent to the City of Cedar Falls to hold my child’s medication for this Recreation Division Program. The medication must be in the original container and contain no more than a 5-day supply. I understand that the Cedar Falls Recreation Division will hold them before & after the child is to take it. It is not the responsibility of the Cedar Falls Recreation Division to make sure my child has received the proper dosage. If a pill is to be taken as a half, the pills must be cut in half by the parent.
The following medication has been received from (Parent/guardian) for use by my child (child's name) blank.
Staff Signature & Date
Should be Empty:

Cedar Falls Recreation Camp CF Participant Information

MEDICAL CONSENT FORM AND HEALTH CARE INFORMATION

CONSENT FOR GIVING MEDICATIONS: