Farm CAMP Enrollment Form

Name of Preferred Medical Provider in Case of Emergency

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Does your child have any food, medication or environmental allergies?*

YesNo

Allergies? Check all that apply*

FoodMedicationEnvironmental

Please list and explain any allergies*

0/150

Does your child’s allergy/allergies require staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child?*

YesNo

Does your child have a special health or medical condition?*

YesNo

Please explain*

0/150

Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during child care hours?*

YesNo

Is your child currently using any medication? *

YesNo

Please explain*

0/150

Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?*

YesNo

Please explain*

0/150

List any additional health concerns that would be needed to assist the staff or medical personnel in an emergency situation.*

0/200

List any additional information about your child that would be useful for staff to know, such as fears, eating habits, behaviors or special routines. This information should not be medical or health related, as that information should be included in the previous questions.*

0/200

Check all that apply

Name of medication*

Exact dosage*

To be administered at the following times*

For the following period of time*

***Note we are unable to admisiter medications or accomdate medical requests during camp times if your child's medication meets any of these criteria:

A physician's instruction is needed for a nonprescription medication (e.g. child is underage or underweight per the label instructions); or
It is a sample medication without a prescription label; or
The nonprescription medication is to be given longer than three consecutive days within a fourteen day period or is a topical product or lotion that is being used for a skin ailment and is to be given no longer than fourteen consecutive days; or
The medication contains codeine or aspirin.

Prigel Family Farm will not provide over the counter medications, suncreens, bug sprays etc. to campers but we will assist with applying products sent from home with parental consent.

*** Please note that while there will be a CPR and First Aid trained staff member at all times. there will NOT be a registered nurse on site. Prigel Family Farm reserves the right to require families to provide medical assistance for medication administration that is beyond our scope of training.***

Farm Camp Registration Form

Camper's Information

Parents' Information

Parents' Information

Emergency Contacts/Authorized Pickup

Emergency Contact/Authorized Pick Up

Emergency Contact/Authorized Pick Up

Medical / Health Information

Additional Medication