HEALTH INFORMATION FORM

HEALTH INFORMATION FORM
To be completed by Parent or Guardian

NorthBay wants the camp experience to be a safe and healthy one. However, in the event of an accident or illness, it is important that we have the following information including medical history, insurance information, permission to give selected over the counter medications, and custodial parent signatures.
SCHOOL NAME
FIRST DAY AT CAMP

MonthDayYear
Date
LAST DAY AT CAMP

MonthDayYear
Date
Name

First NameLast Name
MI
Date of Birth

MonthDayYear
Date
Grade
Preferred Name
Ethnicity(Optional)
Gender: Male/Female/NonBinary
Parent/Guardian #1 Name
Relationship to Camper
Email Address
example@example.com
Do you wish to receive NorthBay marketing emails?
Will you be coming as a chaperone?
Phone Number #1
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number #2
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #2 Name
Relationship to Camper
Email Address
example@example.com
Do you wish to receive NorthBay marketing emails?
Will you be coming as a chaperone?
Phone #1
Format: (000) 000-0000.
Phone #2
Format: (000) 000-0000.
Emergency Contact

First NameLast Name
Phone #1
Format: (000) 000-0000.
Phone #2
Format: (000) 000-0000.
Insurance?
Insurance Company
Policy Number
Campers Primary Care Physician
Office Telephone Number
Format: (000) 000-0000.
Office Fax Number
Health History(check if applicable)

Other
Date of last Tetanus shot

MonthDayYear
Date
Medication Allergies(list all)
Food Allergies(list all)
Insect Allergies(list all)
Poison Ivy Allergy
Other Allergies(list all)
Diet and Nutrition

Other
Does the camper need their physical activity restricted?

Other
Please provide any additional information that we may need to know to ensure your child's camp experience is a good one
PARENT / GUARDIAN CONSENT AND LIABILITY RELEASE FORM
At NorthBay, health, safety and supervision are paramount. The approach to safety and risk management is accompanied with competence, judgment and purposeful sound programming. The children’s safety and well-being is everyone’s concern. As a policy of NorthBay we require that a Health Information Form be signed as a requirement to attend camp.I represent that I am the parent or legal guardian of (the “Camper”) who desires to attend camp and participatein activities sponsored by NorthBay, Education Inc. In consideration for NorthBay permitting the Camper to attend the camp andparticipate in the activities, I have agreed to execute this Health Information Form. I assert the information given on this Health Information Form is complete and accurate to the best of my knowledge. I also represent that the Camper has received all immunizations as required by the Maryland DHMH Recommended Childhood Immunization Schedule and that these records have been provided to theschool system. In the event I cannot be reached in an emergency when my child is under camp supervision, I hereby give permission to the physician selected by the camp director to hospitalized, secure proper treatment for, and/or order injections, anesthesia, or surgery formy child. If something were to happen to my child a doctor selected by the camp may treat him/her for any injury/illness. I givepermission to the camp to administer any prescription or nonprescription medications that the student brings to camp with them in accordance with Maryland law. I understand that my child will participate in outdoor and environmental education activities including but not limited to: ropes course, zip line, climbing wall, kayaking, canoeing, wading, fishing, and hiking. As a part of the NorthBay experience, we are always trying to improve our programs to provide the best possible experience for our visiting students. As part of thiseffort, an external evaluation team periodically conducts research. This research involves observing our programs and conducting student surveys. Your student might be invited to participate in small daily discussion groups with the researcher. These daily discussion groupswill be audio recorded. All data are kept strictly confidential. Students are not held responsible for any of their responses. The research occasionally results in publications that report on the accomplishments of our programs and what we are learning, so that other programs like ours can learn from our work. By signing this permission form, you are consenting to allowing your son/daughter to participate in this research. Students maintain the right to refuse to take part in any survey or daily discussion group with no fear of any consequences or penalties
AUTHORIZATION FOR OVER-THE-COUNTER MEDICATIONS - In the event your child experiences minor discomforts during camp, we would like the opportunity to make your child as comfortable as possible. Therefore, below is a list of over-the- counter medications that can be administered by NorthBay personnel with your authorization. These medications are approved by the NorthBay Medical Director using the recommended doses from the manufacturers. This service is provided to alleviate your child's minor discomforts and avoid being sent home early from camp. The below approved medications are intended for occasional use only. If your child requires any medication on a regular basis, you must have a medication authorization form completed by your health care provider and supply the medications. I consent to the administration of the below indicated over-the-counter medications to my child while at NorthBay If they are NOT checked they WILL NOT be given to the Camper.
Authorization for over-the-counter medications
I represent that I am the parent or legal guardian of blanks*("Camper") who desires to attend camp and participate in activities sponsored by NorthBay Education, Inc. I give permission to NorthBay the right to use, reproduce, and/or distribute photographs, films, video-tapes, and sound recordings of the Camper, without payment or approval rights, for use in materials created solely for promoting.
Signature of Parent/Guardian
Date

MonthDayYear
Date
Cell Phone Policy

Phones may not be used in cabins or bathrooms at any time to protect the safety and privacy of your child and others. If phones are brought to NorthBay, they will be kept in the safe in the cabins during the program and will only be accessible during scheduled times. The schedule varies based on activities, but we aim for about 15 minutes per evening between 9:15pm and 10:00pm. If students have cell phones outside of scheduled time, we will notify you and the phone will be taken, held in the Administration Building, and returned to the school's Point Person at the end of the week. NorthBay's office phones are available for students to call home during mealtimes. Mealtimes are 8:30am-9:15am, 12:00pm-12:45 pm and 6:15pm-7:00pm. If you call our front desk 443-967-0500 or email studentmessages@northbayeducation.org we will make sure your student gets your message at the next mealtime.
I also understand and agree to abide with the restrictions placed on my camp activities as listed above.
Signature of Parent/Guardian
Date

MonthDayYear
Date
Should be Empty:

HEALTH INFORMATION FORM

PARENT / GUARDIAN CONSENT AND LIABILITY RELEASE FORM

Cell Phone Policy