Compassion Camp for Kids Health and Waiver Form 2024

Camper Information:

Name:*

Birth Date:*

Gender: *

Grade entering in the Fall:*

Mailing Address:*

Street/PO Box, City, State and Zip

Parent/Guardian #1:

Name:*

Relationship:*

Phone:*

Email:*

example@example.com

Parent/Guardian #2:

Name:

Relationship:

Phone:

Email:

example@example.com

Emergency Contact:

(If parents/guardians cannot be reached)

Name:*

Relationship:*

Phone:*

Health Care Information:

Provider:*

Doctor or LNP

Phone:*

Name of Practice:*

Address:*

Insurance Carrier/Plan Name:*

Policy #:*

Subscriber Name:*

Subscriber's relationship to camper:*

Gender identity:*

Camper Height:*

Camper Weight:*

Medical History:

Have asthma?*

YesNo

Have diabetes?*

YesNo

Have seizures or seizure disorder?*

YesNo

Other recurrent/chronic illness?*

YesNo

Been hospitalized/had surgery in past 2 yrs?*

YesNo

Ever had head injury or concussion?*

YesNo

Have stomach or intestinal issues?*

YesNo

Had severe or frequent headaches?*

YesNo

Passed out/had chest pain during exercise?*

YesNo

Had fainting or dizziness?*

YesNo

Have frequent bloody nose?*

YesNo

Ever had back/joint problems?*

YesNo

Ever been stung by a bee?*

YesNo

Have any skin problems?*

YesNo

Please explain any "yes" answers to the medical history

Mental, Emotional, Behavioral and Social History:

Does your child require a one-on-one aid at school?*

YesNo

Ever been treated for ADD or ADHD?*

YesNo

Have a phobia?*

YesNo

Ever been treated for emotional/behavioral difficulties, self-harm, or eating disorder?*

YesNo

During the past year, seen a professional to address mental/emotional health concerns?*

YesNo

Used an individual education plan (IEP) during school year?*

YesNo

Have a significant life event that continues to affect camper’s life? (recent divorce, foster care, trauma, etc)*

YesNo

Please explain any "yes" answers to the mental, emotional and social history:

Allergies:

Allergies?*

YesNo

Food?*

YesNo

Environmental?*

YesNo

Risk of anaphylaxis?*

YesNo

Please explain any "yes" answers and tell us an emergency plan:

Any activity restrictions?*

YesNo

Please explain the activity restrictions:

Diet and nutrition:

No diet restrictionsGluten-free dietVegetarianVegan

Medications:

Please list all medication needed during camp hours. Include emergency medications. All medications must be unexpired and in original containers. Prescription medications must include the pharmacy label.

List of medications regularly taken AT HOME:

Medications at Camp?*

No, this camper will not be taking any medications at campYes, this camper will bring medication to camp

Asthma Emergency Medications:

Camper needs asthma medication only for respiratory illness and will NOT bring it to campYes, this camper has asthma mediation they will bring to camp

Asthma medication:

Dose:

Strength:

Form (drops, etc.):

As needed or time(s) given?

Reason:

Camper can self-administer?

Camper needs assistance?

Camper will also bring spacer and/or nebulizer?

Emergency Allergy Medications:

Yes, this camper will be bringing EpiPen to camp. (EpiPen must have a pharmacy label).Camper can self-administer medicationCamper needs assistance with medication

Other Allergy Medication?

Strength:

Form (drops, etc.):

As needed or time(s) given?

Reason:

Medications Needed During Camp Hours:

Medication #1

Dose:

Strength:

Form (drops/tablet, etc.):

As needed or time(s) given?

Reason:

Medication #2

Dose:

Strength:

Form (drops/tablet, etc):

As needed or time(s) given?

Reason:

Medical Waiver and Authorization (required for participation):

Medical release: This health history is correct and accurately reflects the known health status of the named camper. The camper described has permission to participate in all camp activities except as noted by me and/or their physician. I give permission to camp staff to provide routine health care; to administer prescribed or over-the-counter medications as described; and to provide or obtain emergency care and transportation for the camper if needed. I will also provide a copy of my child’s complete immunization records prior to June 1st.

Medications: I authorize Pope Memorial SPCA staff to administer as listed above medications at camp and asthma or allergy emergency medications, as directed, to my child for whom was prescribed. I understand that all medications at camp must be approved, seen and checked by the camper’s supervisor, and each dose monitored by a camp staff member. I understand that all medications must be in their original containers, unexpired, and labeled with specific instructions, including the child’s name and dosage, and that any prescription medications must include the full pharmacy label.

Insurance: I certify that the named camper is covered by health and accident insurance or Medicaid and that the policy information given is correct.

I, the parent/legal guardian of the named camper, have read, understood, and agree to abide by the terms and policies listed above.

Signature of Parent/Guardian*

Print Name*

Relationship to camper*

If available, please upload your child's complete immunization records and documentation of their last physical exam; exam must be within two years of start of camp session. If unavailable, please submit by June 1st.

Release/Pick Up:

My camper may be released to the following adults - other than parent & emergency contacts (include first and last names):

Name:

First and Last name

Relationship:

Phone:

Name:

First and Last name

Relationship:

Phone:

Parent/guardians may send a note to make changes to this list. People picking up campers must bring a photo ID. If a person not listed above arrives to pick up a camper, the camper will remain with camp staff until the parent/guardian has been contacted and has given permission for the release. If there are specific people to whom the camper may not be released, please inform the camp in writing.

Release/Pick-Up: I, the parent/legal guardian of the named camper, have read, understood, and agree to the release policy as described and authorize Pope Memorial SPCA to release my child to the people listed on this form.

Signature of Parent/Guardian*

Print Name*

Relationship to camper*

Camper Agreement of Terms:

Program: I give permission for my child to participate in all camp program activities. I understand that Pope Memorial SPCA reserves the right to change the program activities or instructors and cancel programs, should Pope Memorial SPCA decide in its sole judgement that it is necessary and appropriate to do so.

I, the parent/legal guardian of the named camper, have read, understood, and agree to the above.

Parent/Guardian Initials*

Exceptions/Dismissal: I have informed the Camp Director and other appropriate Pope Memorial SPCA staff of any limitations to my child's participation and agree to abide by Pope Memorial SPCA sole judgement as to whether my child can be accommodated in the camp program. I understand that failing to disclose any physical, emotional, or behavioral needs and conditions may result in the child's dismissal from the program without a refund. I understand that my child must follow the stated behavior expectations and safety rules and that Pope Memorial SPCA reserves the right in its sole judgement to dismiss without refund any child whose behavior interferes with the rights and safety of others or consistently disrupts group dynamics or activities.

I, the parent/legal guardian of the named camper, have read, understood, and agree to the above.

Parent/Guardian Initials*

Animal Interaction: I do recognize that in conjunction with my child's attendance at Pope Memorial SPCA, my child will be in contact with and maybe allowed to hold shelter animals. I understand that despite all precautions made, there is a chance that my child may sustain a scratch or bite while handling these animals. I understand that the above is illustrative of the types of risks involved in participating in the camp program at Pope Memorial SPCA, but is in no way a complete list of possible risks.

I, the parent/legal guardian of the named camper, have read, understood, and agree to the above.

Parent/Guardian Initials*

Hygiene Protocols: I understand due to COVID-19 virus and communicable diseases that my child may use hand sanitizer with at least 60% alcohol. Hand sanitizer will be securely used under the supervision of staff/volunteers at all times.

I, the parent/legal guardian of the named camper, have read, understood, and agree to the above.

Parent/Guardian Initials*

I also understand I am to follow an at home screening process that involves taking my child's temp prior to attending camp and answering following questions:

At Home Health Screening:

Should you answer "yes" to any questions below, please cancel your child from camp and notify Lillian Lavery immediately (camp@pmspca.org or 603-856-8756 x224) so staff can be updated.

Fever of 100 degrees fahrenheit or greater. Please check your child's temperature prior to camp and be sure it is not greater than 100.00 degrees when attending camp.
Is your child experiencing any respiratory symptoms including a runny nose, sore throat, headache, cough, or shortness of breath?
Is your child experiencing any new muscle aches or chills?
Is your child experiencing any new change in their sense of taste or smell?
Has your child been exposed to someone who has had COVID in the last 7 days?

If your child has experienced any of the following symptoms within 48 hours prior to the first day of camp, your child may not attend camp.

Any person that develops symptoms of COVID while at camp will be removed from the group, and arrangements will be made immediately for your child to be picked up. If your child is sent home from camp with any of these symptoms, they must be symptom-free for 24 hours and obtain a doctor's note before returning to camp.

I, the parent/legal guardian of the named camper, have read, understood, and agree to the above.

Parent/Guardian Initials*

Camp Health Screening: Staff will take each camper's temperature, ask the above screening questions and about exposure to illness as part of our routine health screening each day.

Payment, Cancellation, and Refund:

I understand and agree to the payment, cancellation refund policies, as listed on Pope Memorial SPCA website and are as follows:

The first $50 paid for each registration is nonrefundable. (If the SPCA must cancel a session, you will receive a refund of all fees paid.)
Refunds are not given for dismissal, failure to attend, absence, or sick days.
If you cancel before the start of your camp session, the amount of the refund is determined by the following schedule:
- Before June 1st: all but $50 refunded
- After June 1st: no refund available

I have read and agree to abide by the terms and policies listed above. I, the parent/legal guardian of the named camper, have read, understood, and agree to the above.

Signature of Parent/Guardian:*

Print Name:*

Relationship to camper:*

Audio/Visual Image Release: Pope Memorial SPCA uses images and sounds of children and staff participating in Pope Memorial SPCA programs as a way of documenting the enjoyable and educational experiences they have while working with and learning about animals. Pope Memorial SPCA will identify my child only by first name and program, unless I give written permission to do otherwise.

In consideration, of the above, I hereby give my permission and consent to Pope Memorial SPCA.

Photographing, filming, and video/audio taping of my child.
Using and displaying images and sounds of my child in Pope Memorial SPCA websites, social media, archives, and promotional or informational material, including but not limited to, newsletters, brochures, advertisements, and newspaper articles.

I hereby waive and release on behalf of my child and myself any right to compensation for, or ownership of, such images and/or sounds of my child and the above uses of them by Pope Memorial SPCA.

I, the parent/legal guardian of the named camper, have read, understood, and agree to the audio/visual image release and its terms and conditions.

Signature of Parent/Guardian:*

Print Name:*

Relationship to camper:*

Acknowledgement of Risk & Assumption of Personal Responsibility:

Pope Memorial SPCA staff members and volunteers make every effort to conduct safe programs, to orient and support children, and to inform families of inherent risks. Some activities may involve risks that children do not routinely encounter at home.

I understand that program activities may include, but are not limited to; playing active games, being near shelter animals and hikes through Audubon trails.

I acknowledge that such risks exist, and I hereby agree on behalf of my child to assume such risks. Further, on behalf of my child, I hereby release and forever discharge, and agree not to sue, and agree to indemnify and hold harmless, Pope Memorial SPCA of Concord-Merrimack County, and it officers, directors, employees, and volunteers and each of them, from and against any and all liabilities and obligations of every kind and description, which I shall or may have against them or any one or more of them arising out of, or in connection with, my child’s participation in the Pope Memorial SPCA program and activities, including, but not limited to, sickness or death caused by the COVID-19 virus or any other communicable disease, or for any personal injury or loss of personal property that my child may suffer while participating in Pope Memorial SPCA program and activities, excepting in the case of gross negligence by Pope Memorial SPCA.

I understand that the COVID-19 virus is an extremely contagious virus that spreads easily through person-to-person contact. The Center for Disease Control and the New Hampshire Department of Public Health authorities recommend social distancing, face coverings, cleaning and sanitizing procedures, and small group sizes to prevent the spread of the COVID-19 virus. The COVID-19 virus can lead to severe illness, personal injury, permanent disability and death. Participating in Pope Memorial SPCA programs of accessing Pope Memorial SPCA facilities may increase the risk of contracting the COVID-19 virus. All Pope Memorial SPCA camp staff and volunteers have been trained to follow all appropriate and state and federal mandated guidelines to prevent contracting of the COVID-19 virus.

I understand and agree, on behalf of my child, that my child shares the responsibility for safety during Pope Memorial SPCA programs and activities, and I personally assume on behalf of my child that responsibility. I understand and certify that my child’s participation in Pope Memorial SPCA program and its activities is completely voluntary, and that I have become familiar with the program activities in which my child may participate, as described in the Agreement of Terms.

I, the parent/legal guardian of the named camper, have read, understood, and agree to the Acknowledgement of Risk & Assumption of Personal Responsibility release and to its terms and conditions.

Signature of Parent/Guardian:*

Print Name:*

Relationship to camper:*