AF Emergency Contact + Short Health Form

2024 Health History Form (Digital)

Please complete this online digital form. You will need to complete the emergency contacts and alert us to any pertinent allergies.
Participant Name*

First NameLast Name
Emergency Contact Information

Please provide emergency contacts in the event there is an emergency while you or your child is at Ambler Farm.

Primary Contact:
Name*
Relationship*
Cell phone number*
Alternate phone number*
Secondary Emergency Contact:
Name*
Relationship*
Cell phone number*
Alternate phone number*

Restrictions and Other Comments
Based on the programs and activities, are there any medical restrictions to prevent participation in these programs?*

YesNo
Please describe any restrictions if any:
Is there anything else we should know about yourself / child?
Parent / Guardian / Self Authorization For Health Care

This health history is correct and accurately reflects the health status of the participant to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of the applicant for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this applicant. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of the applicant's health record from providers who treat the applicant and these providers may talk with the program’s staff about the applicant's health status.
Parent/ Guardian / Self Signature (Enter your full name)*

Clear
Parent / Guardian Printed Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
What is the name of the program you are participating in?*
Should be Empty:

2024 Health History Form (Digital)

Emergency Contact Information

Please provide emergency contacts in the event there is an emergency while you or your child is at Ambler Farm.

Primary Contact:

Secondary Emergency Contact:

Allergies

Leave allergen sections blank if there are no allergies.

Allergy #1

Allergy #2

Allergy #3

Restrictions and Other Comments

Parent / Guardian / Self Authorization For Health Care