WEEK 24: Creekside - MINOR HEALTH FORM

MOUNT HERMON OUTDOOR SCIENCE

MINOR HEALTH FORM
Student Information
Student's Legal Name*

First NameLast Name
MaleFemale
Date of Birth*

MonthDayYear
School*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information

To be contacted in case of illness or injury
Parent/Guardian Name*

First NameLast Name
Relationship to Student*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email*
example@example.com
Secondary Parent/Guardian Information

To be contacted in case of illness or injury
Secondary Parent/Guardian Name

First NameLast Name
Relationship to Student
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Student Doctor/Insurance Information
Name of student's primary doctor
Primary Doctor Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Insurance Company*
Subscriber*
Policy Number*
Insurance Company Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

Student Health Questionnaire
This student has NO dietary restrictionsThis student eats a GLUTEN FREE dietThis student eats a DAIRY FREE dietThis student eats a VEGETARIAN dietThis student has additional dietary needs
Please describe this student's dietary needs*
Our standard menu includes beef, pork, chicken, eggs, dairy and gluten products. If your student is unable to consume one or more of these items that MUST be noted above.

If your student has multiple dietary restrictions (e.g. dairy free and gluten free), severe food allergies, or additional dietary restrictions please contact us to request a sample menu. You may need to provide food for your student for their time at Outdoor Science School.
YesNo
Please describe any allergies and the reaction seen*
All swimming at Mount Hermon OSS takes place under the supervision of American Red Cross certified life guards.
YesNo

Immunization History

Provide month and year for each immunization. If the immunization has not been received write 'None' in the space provided. Mount Hermon is required by law to gather this information.
Diptheria, Tetanus, Pertussis, (DTaP) or (TdaP)
Dose 1  (month/year)

Dose 2 (month/year)

Dose 3 (month/year)

Dose 4 (month/year)

Dose 5 (month/year)

Tetanus Booster (dt) or (TdaP)
Most Recent Dose (month/year)

Mental, Emotional and Social Health
YesNo
YesNo
YesNo
YesNo
Please explain any "Yes" answers in the space below, noting the question number.

What have we forgotten to ask? Please provide any additional information about the student's health that you think important or that may affect their ability to fully participate in the Outdoor Science School program.

This health history is correct and accurately reflects the health status of the student to whom it pertains. The person described has permission to participate in all Mount Hermon Outdoor Science School activities except as noted by me and/or and examining physician. I give permission to the physician selected by Mount Hermon Association to order x-rays, routine tests, and treatment related to the health of my child 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 child.*

Clear
I understand the information on this form will be shared on a “need to know” basis with OSS staff. I give permission to photocopy this form. In addition, Mount Hermon Association has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.*

Clear
I am aware that, at the discretion of the Science School Director, I will need to pick up my child due to medical or disciplinary reasons. I agree to be responsible for picking up my child. Mount Hermon Outdoor Science School policy is that in the event that a child needs to be sent home for any reason, no amount of the paid fees will be refunded if my child has attended the Outdoor Science School program for 24 hours or more.*

Clear

Risk Agreement Form
Mount Hermon Outdoor Science School welcomes you to participate in a fun, exciting and educational adventure at its facilities. Participation with the Outdoor Science School is not without risks and Mount Hermon wants you to be fully aware of the risks connected with various activities so you can make a fully informed decision regarding participation.

Please read this document carefully. It must be signed by all Mount Hermon Outdoor Science School Participants. If the participant is a minor, at least one parent or guardian must also sign as evidence of their agreement to these terms and conditions on their own behalf and on behalf of the minor. By signature below, the undersigned party(ies) certifies and agrees as follows:

1. Voluntary Authorization. The participation of the undersigned, and/or if applicable, the participation of the undersigned's child(ren) in Mount Hermon activities and programs is completely voluntary, and the undersigned's authorization of such participation is completely voluntary. The undersigned, acknowledges that he and /or if applicable, the undersigned's child(ren) do not have any medical condition which might create a risk of safety for them or for others who are participating in the activities and programs.
2. Acknowledgment of Risks. The undersigned understands the Mount Hermon activities and programs and those in which the undersigned’s child(ren) will be participating. Further, the undersigned fully acknowledges and has instructed his child(ren) in the importance of abiding by Mount Hermon’s rules, regulations and safety procedures. The undersigned recognizes that certain hazards, risks and dangers are inherent by the physical location of the Mount Hermon facilities and in its numerous activities and programs. These include, but are not limited to the use of unpaved trails, the participation in large and small group games, swimming, diving, rock climbing, roped tree climbing, zip lining, use of high ropes/adventure courses, target activities such as archery and various other sporting activities. These activities have related hazards and risks such as falls, dizziness, stress, bruises, scratches, strains, sprains, contact with poisonous plants, heat exhaustion, dehydration, embarrassment, anxiety, collisions, equipment failures, contact with other participants, eye injuries, joint or back injuries, heart attacks, and concussions. The undersigned acknowledges that this description of risks and hazards is not complete and that other unknown or unanticipated risks may result in illness, injury, death, and loss, both to person and property and that the risks may be extremely serious.
3. Assumption and Acceptance of All Risks. In consideration of allowing participation in Mount Hermon activities, today and on all future dates, the undersigned knows, understands and appreciates that the above specified risks and other unknown or unanticipated risks may occur by the participation in Mount Hermon's activities and that the undersigned and/or on behalf of his child(ren) voluntarily assumes and knowingly and fully accepts all known and unknown risks and injuries.
4. Release of Claims and Waiver. Further, in consideration of Mount Hermon permitting the undersigned and/or his child(ren) to attend or visit the property of Mount Hermon and participate in its activities and programs, the undersigned for himself, his estate, heirs, assigns and/or on behalf of his child(ren) releases Mount Hermon and its trustees, directors, officers, managers, employees, agents, volunteers, its affiliated organizations, representatives and successors (hereinafter "Related Parties") from any and all liability and waives any and all claims for personal injury, loss or damage, including attorneys' fees, in any way connected with or arising out of Mount Hermon's activities, programs or facilities from whatever cause, excluding therefrom any intentional and/or willful acts of misconduct by Mount Hermon.
5. Indemnity. On behalf of the undersigned, and/or if applicable his/her child(ren), the undersigned hereby agrees to indemnify, defend, protect and hold harmless Mount Hermon and Related Parties for and from any and all claims for any liability, injury, loss, damage, or expense, including attorney's fees (including cost of defending any claim the undersigned might make or that might be made on behalf of the undersigned and/or the undersigned's child(ren)), which is in any way related to or arising out of the undersigned's and/or the undersigned's child's(ren's) participation in Mount Hermon activities and programs, excluding therefrom any intentional and/or willful acts of misconduct by Mount Hermon.
6. Property Damages. The undersigned understands and agrees that he is responsible for any damage to Mount Hermon property caused, in part or whole, by the undersigned and/or his child(ren). The undersigned agrees that Mount Hermon or Related Parties will not be responsible or liable in any manner for the personal property of the participants.
7. Medical Treatment and Transportation. The undersigned authorizes Mount Hermon to obtain such medical care or transportation as it considers necessary and appropriate on behalf of the undersigned, and/or if applicable his child(ren), and the undersigned shall pay all costs associated with such medical care and transportation.
8. Additional Provisions. Throughout this form, except where the context requires otherwise, the gender shall be deemed to include the feminine and masculine, and the singular number shall be deemed to include the plural, and vice versa. Any dispute between Mount Hermon or a Related Party and the undersigned will be governed by the laws of the State of California, and any arbitration or suit shall take place in the State of California and County of Santa Cruz. If any provision of this document is held to be void or otherwise unenforceable by a court of competent jurisdiction, the remaining provisions shall nevertheless be fully enforceable and unimpaired by such holding. The undersigned additionally authorizes to receive future promotional information about upcoming Mount Hermon events.

The undersigned warrants and represents that he has authority to release and waive the foregoing for himself, his estate, heirs, assigns and if applicable his child(ren) being registered for camp, that the undersigned is at least eighteen (18) years of age and is under no mental or legal disability which would prevent him from understanding, signing and executing this document. The undersigned further represents that he has carefully read and fully understands the terms contained herein and that this is a release of liability, waiver and indemnity in which the undersigned is giving up important legal rights and that it is a contract between the
undersigned and Mount Hermon and/ or its affiliated organizations and its Related Parties.
Parent/Guardian Signature*

Clear
Student Signature*

Clear
Should be Empty:

MOUNT HERMON OUTDOOR SCIENCE

Student Information

Parent/Guardian Information

Secondary Parent/Guardian Information

Student Doctor/Insurance Information

Student Health Questionnaire

Medications, Vitamins, Supplements

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

OTC Medication Authorization

Immunization History

General Student Health History

Mental, Emotional and Social Health

Risk Agreement Form