Summer Camp at Ohio FFA Camp Muskingum

Session 3 Student Health Form/Release/Code of Conduct
IMPORTANT

If you are feeling unwell or have any of the follwing symptoms, please DO NOT attend FFA Camp.

Symptoms include:
- Fever/chills
- Persistent Cough
- Shortness of breath/trouble breathing
- Fatigue
- Body aches
- Severe Heachache
- Recent loss of taste/smell
- Sore throat
- Sinus congestion/runny nose
- Nausea/vomitting
- Diarrhea
All students are required to have a completed and submitted health form and release prior to arriving at Ohio FFA Camp Muskingum.

Any previously submitted healthforms are not valid and a new form must be completed for each student attending camp.
Email of Person filling out this form
You will receive a copy when submitted.
School Information

Please provide the following information regarding the school your camper attends.
School Name*
FFA Advisor/Ag Teacher Name*
FFA Advisor/Ag Teacher Email*
example@example.com
Student Information
Student Name*

First NameLast Name
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Male/Female*

MaleFemale
Student Age*
Last 4 digits of Student's Social Security Number
This is needed in case we have to take your student to the hospital.
Student Medical Information

Please complete all sections accurately
Student Birthday*

MonthDayYear
Date
Is the student covered by family medical insurance?*

YesNo
Insurance Company Name*
Name of primary insurance holder*
Insurance ID/coverage number*
Food Allergies

This section is for food allergies. Please list any applicable. Note: There is a later section for dietary restrictions, such as vegan/vegetarian.
Does your student have food allergies?*

YesNo
Food Allergy #1*
Food Allergy #1 Details*
Food Allergy #2
Food Allergy #2 Details
Food Allergy #3
Food Allergy #3 Details
Food Allergy #4
Food Allergy #4 Details
Food Allergy #5
Food Allergy #5 Details
Does your student have dietary restrictions? (Vegan, vegetarian, etc)*

YesNo
Dietary Restriction #1.*
Dietary Restriction #2.
Dietary Restriction #3.
Dietary Restriction #4.
Dietary Restriction #5.
Seasonal/Other Allergies

Please list any allergies the Camp Nurse should be aware of.
Seasonal/Other Allergies?*

YesNo
Allergen #1*
Allergen #1 Details*
Allergen #2
Allergen #2 Details
Allergen #3
Allergen #3 Details
Allergen #4
Allergen #4 Details
Allergen #5
Allergen #5 Details
Medication
IMPORTANT

All medication MUST be in original container/bottle.

Daily sorters/pill keepers are NOT permitted.
If your child must take any medication, carefully read the medication instructions below.

Medication WILL NOT be administered unless all of the instructions are properly followed.

It is necessary that the school and camp authorities know you child's physical and mental condition.

If you have any doubt that your child is in good health, have a physician examine your child and forward the report to the camp.

Medication

A. If your child must take any medication, send medicine in the ORIGINAL CONTAINER. Daily sorters/pill keepers are not permittted.

B. PRESCRIPTION MEDICATIONS must be accompanied by a pharmacy label containing the RX number, the name of the medication, and dosage, directions for administration, and the child's name.

C. NON-PRESCRIPTION MEDICATIONS must be in their original containers, clearly labeled with the child's name, name of the medication, and directions for its use.

D. Medicine lying loose in sandwich bags or other containers will not be administered.

E. Your child will not be allowed to keep any medications in the dormitory (Inhalers/Epi-Pens permitted).
Due to program scheduling, medications are given at meal times, then at the end of programming each night.

Times are as follows:

7:30 AM

12:00 PM

5:30 PM

10:30 PM
Does your student take medication regularly that they will take at camp ?*

YesNo
Medication #1 Name*
Medication #1 Details*
Medication #2 Name
Medication #2 Details
Medication #3 Name
Medication #3 Details
Medication #4 Name
Medication #4 Details
Medication #5 Name
Medication #5 Details
Medication #6 Name
Medication #6 Details
Medication #7 Name
Medication #7 Details
Medication #8 Name
Medication #8 Details
Medication #9 Name
Medication #9 Details
Medication #10 Name
Medication #10 Details
IMPORTANT

If your child has been diagnosed with asthma by a physician and has medication including tablets, nebulizers, or inhalers, they MUST bring such treatment with them to camp or they will not be allowed to stay at camp!

If your child has an inhaler, they must keep it with them at ALL TIMES during camp!

If your child requires an epi-pen, they must keep it with them at ALL TIMES!
Does your child have an Epi-Pen?*
Has your child ever been diagnosed with asthma by a medical professional?*
Does your child have any other significant health history (heart condition, diabetes, any injury) or does the camper have any restrictions/medical conditions that the nurse needs to be aware of?*

YesNo
If yes, please explain:*
I give permission for the FFA Camp Nurse to dispense "as needed" over the counter medication to my child*

YesNo
Medication Allergies

Please list any known medication allergies and reactions.
Does your child have any medication allergies?*

YesNo
Medication Allergy #1*
Medication Name
Medication Allergy #1 Details*
Medication Allergy #2
Medication Name
Medication Allergy #2 Details
Medication Allergy #3
Medication Name
Medication Allergy #3 Details
Medication Allergy #4
Medication Name
Medication Allergy #4 Details
Medication Allergy #5
Medication Name
Medication Allergy #5 Details
Emergency Contacts
Parent/Guardian #1 Name*

First NameLast Name
Parent/Guardian #1 Contact Number*
Please enter a valid phone number.
Relationship to Student*
Parent/Guardian #2 Name*

First NameLast Name
Parent/Guardian #2 Phone Number*
Please enter a valid phone number.
Relationship to Student*
Alternate Emergency Contact #1*

First NameLast Name
Alternate Emergency Contact #1 Phone Number*
Please enter a valid phone number.
Alternate Emergency Contact #1 Relationship to Student*
Alternate Emergency Contact #2*

First NameLast Name
Alternate Emergency Contact #2 Phone Number*
Please enter a valid phone number.
Alternate Emergency Contact #2 Relationship to Student*
Parental Consent/Release
I give permission for my child to attend FFA Camp Muskingum and to be subject to the authority of the program director. I give permission for the above to participate in any planned activities under the supervision of the director. I also understand that the director may dismiss my child from the encampment if in their opinion his/her conduct or influence is not in the best interest of the entire group. I will not hold FFA Camp Muskingum responsible or liable for accidents which may occur to the camper while on the camp premises, or for loss of personal articles brought to FFA Camp Muskingum. I also give permission for use of any photo of the above named to be used for program public relations. I understand that my childs participation in programs offered by FFA Camp Muskingum including the adventure activities and living history reenactments are based on a "Challenge by Choice" philosophy. I recognize that the program is designed to use experiential hands on teaching techniques and that my child's participation is purely voluntary. I also understand that my child will have the opportunity to participate in a large array of activities that include the following: Rifle, Shotgun, Archery, Motor Boats, Canoeing, Kayaking, Row Boats, Overnight Campout, Athletic Sporting Events, including Water Sports, High Ropes, Low Ropes, Climbing Wall, and Laser Tag.*

Student First NameStudent Last Name
The following activities are OFF-SITE of Ohio FFA Camp Muskingum. Check the activities that you DO NOT grant permission for your child to participate in:

Off-site Overnight CampoutLocal Agricultural Business TourCarroll Hills/Special Needs Learner Workshop
Consent to Treat/Medical Release
I hereby give permission for emergency treatment of my child in case of accident or illness, and for normal treatment during the program. I realize that FFA Camp Muskingum will make every effort to contact, first the legal guardians, followed by the person to notify in case of emergency. If neither one can be reached, I hereby give permission to the medical personnel selected by the program director and/or assigned staff member to order routine tests, X-rays, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation. I also give permission to the physician selected by the program director and/or assigned member to secure and administer treatment, including hospitalization, for the person named above. I understand that by signing below I have read and understand the above statements.*

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Student Code of Conduct
Ohio FFA Camp Muskingum Code of Conduct

FFA Member: Please read the following, Code of Conduct. If you agree with and are willing to comply with all the expectations of the Code of Conduct and FFA Camp program, please sign at the bottom of the page.

Parent or Guardian: Please read the following, Code of Conduct. Please sign the bottom of this form to show your intent to support the implementation of this Code of Conduct regarding your child.

As an FFA Member attending Ohio FFA Camp Muskingum, I understand that:

* I will conduct myself with respect towards other campers, advisors, and staff, so that I myself may be respected.

*I will conduct myself in a way that will not disrupt the camp program and other campers. Camp reserves the right to amend housing accommodations to maintain a quality camp program and camper experience.

*I will be expected to participate in all aspects of the camp program and follow the daily camp schedule.

*If parental permission is granted on the Health and Registration Form, I can use the swimming area, boating equipment, and rifle, shotgun and archery equipment at those times provided in the camp schedule. Permission from the supervising instructor will be necessary.

*I am personally responsible for any athletic equipment I use, and I will pay for any loss or damage.

*I agree that I am not to have or use any form of tobacco, vape, alcoholic beverages, drugs, or firecrackers while at FFA Camp.

Failure to meet these standards will result in these steps:

1) I will call my parents/guardians and report any conduct not in compliance with these guidelines.

2)At the Director's discretion, this may also result in parent/guardian arranging transportation home.
I have read and understand the above Code of Conduct. I agree to abide by it. *

Student First NameStudent Last Name
Signature of Student*

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Today's Date*

MonthDayYear
Date
Agreement with intent to support:
Signature of Parent/Guardian*

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Today's date*

MonthDayYear
Date
Should be Empty:

Session 3 Student Health Form/Release/Code of Conduct

School Information

Student Information

Student Medical Information

Food Allergies

Seasonal/Other Allergies

Medication

Medication Allergies

Emergency Contacts

Parental Consent/Release

Consent to Treat/Medical Release

Student Code of Conduct