Registration & Medical Information Release Form

Registration & Medical Information Release Form

Winter Wonders Camp
Email*
example@example.com
Camper's Full Name*

First NameLast Name
Nickname or Preferred Name
MaleFemaleOther
Proof of Age Required
Please note, guardians of campers must show one proof-of-age document on the first day of the session before the camper will be permitted to participate. Campers who do not have a proof-of-age document will not be admitted. Billings Farm & Museum will not retain any documents provided.

Acceptable documentation for proof-of-age:
- Birth certificate
- Passport
- Signed doctors note
Proof of Age Policy Acceptance*

I have read the above proof of age requirement and acknowledge it.
Birthdate*

MonthDayYear
Date
Age (8-11 years old)*
Camper's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

In case of illness or injury please contact:*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to Camper*
Person 2:*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to Camper*
Allergies: Please list any allergies your camper has in the space below. Please describe their reaction to allergens and preventative or emergency medications that this camper is prescribed. Please fill in 'N/A' if your camper has no allergies.*
Does your camper carry an EpiPen or an inhaler?

YesNo
If yes, is your camper capable of administering their own medication?

YesNoOther
Please Note: Billings Farm & Museum staff will not administer medication of any kind without prior parental authorization.*

I authorize BF&M staff to administer medication to my camper as prescribed. (A medication dispensing form will need to be completed.)I DO NOT authorize BF&M staff to administer medication to my camper.
Physical, Mental, Emotional and Social Health: Please inform us of any physical, mental, emotional, social, or learning needs that may affect your camper's time with us. We want to be prepared to provide a safe, secure, and successful experience for your child. We will use this information for planning purposes and to support your child in the best way possible. This information will only be shared with BF&M staff member who may interact with your camper. Please fill in 'N/A' if this doesn't apply to your camper.*

Health Care Information
Physician*

First NameLast Name
Physician Phone*
Please enter a valid phone number.
Other

First NameLast Name
Other Phone
Please enter a valid phone number.
Please list any medications and dosage your camper is taking:*

Program Permissions

I herby give our permission for our child/ward named above to participate in the full range of this program's activities. I understand Billings Farm & Museum is not responsible in the event of accident or illness; I will assume all risks of injury and loss arising or resulting from my child/ward's participation, herby releasing and holding harmless Billings Farm & Museum, its employees or agents from liability for any such injury or loss. Furthermore, in the event that Billings Farm & Museum is unable to reach emergency contacts by phone while my child/ward is participating in a Camp, or it medical treatment or procedures are immediately or imminently necessary without delay, I herby authorize Billings Farm & Museum staff and medical personnel to take emergency measures as needed to safeguard their health and well-being. I authorize the staff of Billings Farm to take my child/ward on walking field trips associated with the camp program. I herby consent to and grant Billings Farm & Museum permission to use photographs and videos of my child/ward at the Billings Farm & Museum for media purposes.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Medical Information

Include any prescription and over-the-counter medication that your minor child takes on a regular basis and will need to take while at Billings Farm & Museum Camp.
Medication 1:
Dosage
Time(s) dispensed
Dispensing Instructions
Possible Side Effects
Completed Dosage Instructions
Medication 2:
Dosage
Time(s) dispensed
Dispensing Instructions
Possible Side Effects
Completed Dosage Instructions
Medication Dispensing Policy and Permission to Dispense Medication

1) In all cases, the term "medication" refers to a medicine that has been prescribed by a licensed physician or that is taken by the camper on a regular basis and is needed to maintain the health and well-being of the camper during the duration of the camp. 2) My child has permission to carry and knows how to properly use their own inhaler/EpiPen and has been instructed not to show or share it with other campers. 3) I understand that it is my responsibility to give my camper's medication directly to Billings Farm & Museum staff. I understand that all medications must be in their original containers either in individual dosage containers or in original prescription bottles and must be labeled with the following information: Name of Camper, Medication, Dosage, Time of day to be given, Prescribing Doctor, Doctor's phone number. 4) In all cases, medication dispensing can only be changed or modified by completing a new Camper Medication Information, Permission, and Waiver. 5) In all cases, the term "administration" is equivalent to camp staff maintaining possession of the medication and/or placing it in a secure location until the time it is needed. The medication is given to the camper to take at the documented time. 6)I understand that measurement of medication dosage is not the responsibility of camp staff and must come to camp with the medication pre-measured for the correct dosage. 7) I herby acknowledge that the above information provided for the dispensing of medication for my child/ward is accurate. I also understand that it is my responsibility to inform the museum of any changes in the dispensing of medication.
I, (fill in your name below) give permission to the Billings Farm & Museum staff to administer to my child/ward the medication(s) listed below.

First NameLast Name
Medication(s):
In all cases the recommended dosage of any medication will not be exceeded. If after administering medication there is an adverse reaction, I give my permission to the Billings Farm & Museum to secure from any licensed hospital physician and/or medical personnel any treatment deemed necessary for immediate care. I agree to be responsible for payment of any and all medical services rendered.

Clear
Date

MonthDayYear
Date

Waiver and Release of All Claims

I recognize and acknowledge that there are certain risks of physical injury in connection with the administering of medication to my child/ward. Such risks include, but are not limited to, failing to properly administer the medication, failing to observe side effects, failing to assess and/or recognize an adverse reaction, failing to assess and/or recognize a medical emergency, and failing to recognize the need to summon emergency medical services. In consideration of the Billings Farm & Museum administering medication to my child/ward, I do hereby fully release or discharge the Billings Farm & Museum and its officers, agents, volunteers and employees from any and all claims from injuries, damages and losses I or my child/ward may have (or accrue to me or my child/ward), and arising out of, connected with, incidental to, or in any way associated with the administering of medication.
Signature*

Clear
Date*

MonthDayYear
Date

Camp Drop-Off and Pick-Up Policy

Direct contact between a camper's parent/guardian and camp counselors ensures a safe transition between camp and home, as well as providing an opportunity for you and camp staff to touch base directly. For these reasons, we ask that parents/guardians (or your camper's supervising adult) sign children in and out directly with their camp counselors. Please be sure that you or a supervising adult is available to check campers in and out for each day of camp that they attend. Please list all adults below who are permitted to pick up your child from camp. Additional adults can be added to this form or by providing a note signed by the parent/guardian who signs this policy form. For you camper's safety, please understand that we cannot release a camper to any person who is not on this list or authorized in writing to pick up your camper. Any adult that we do not know, or have not met yet, will be asked to present a photo ID before we release your camper to them. Please Note: camp drop-off is between 8:45-9:00 AM and camp pick-up is between 4:00-4:15PM for Winter Wonders Camp. Pickups later than 4:15 PM are subject to an additional $20 fee.
In addition to myself, the following adults are permitted to pick up my camper:*

First NameLast Name
Relationship to Camper*
Authorized Pick-Up Person 2

First NameLast Name
Relationship to Camper
Authorized Pick-Up Person 3

First NameLast Name
Relationship to Camper
Transportation Policy

Campers may be transported to/from the following outlets: Billings Farm & Museum and Kelly Way Gardens. Camp counselors will ride with campers to oversee the safety of all riders. Campers will stay seated and wear seat belts at all times while riding, and will not be permitted to consume drinks, food, candy or gum while riding. If your camper requires a booster seat, please leave the seat at camp (labeled with your camper's name) at the time of drop-off. Campers will not be allowed to ride in a personal staff vehicle, or any vehicle other than the designated camp vans/buses.
I have read and understand the Billings Farm & Museum Camp policies that are outlined above.*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Registration & Medical Information Release Form

Proof of Age Required

Health Care Information

Program Permissions

Medical Information

Medication Dispensing Policy and Permission to Dispense Medication

Waiver and Release of All Claims

Camp Drop-Off and Pick-Up Policy

Transportation Policy