Medical Form

Today's Date

Date

Date of Program

Date

Child's Name

First NameLast Name

Age:

Gender:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mother/Guardian

First NameLast Name

Father/Guardian

First NameLast Name

Email Address

example@example.com

Email Address

example@example.com

Contact Number

Format: (000) 000-0000.

Contact Number

Format: (000) 000-0000.

Emergency Contact #1

First NameLast Name

Contact Number

Format: (000) 000-0000.

Emergency Contact #2

First NameLast Name

Contact Number

Format: (000) 000-0000.

Emergency Contact #3

First NameLast Name

Contact Number

Format: (000) 000-0000.

The following person(s) may be dropping off/picking up my child(ren):

Please list name, relationship & phone number for each.

Is your child allergic to certain foods or other substances? If so, name foods or substances to be avoided and procedure to follow if reaction occurs.

Please list any past health treatments, relevant medical history or mental health events that we should be aware of:

Does your child(ren) receive resource support from school (paraprofessional) and/or do they require the same support at camp? If so, please explain:

Has your child(ren) been diagnosed with, or being treated for a physical, mental, emotional, or cognitive condition that may affect their health and wellbeing, the wellbeing of others, or affect their ability to engage in camp activities with other campers? If so, please explain:

Is your child taking any medication? If so, will the medication need to be administered during our program?

Please note: Students may NOT carry any kind of medication. It must be kept with a Highlands Center staff person and administered according to a doctor’s or parent’s instructions. All medication must be in the original container and show instructions. In the case of prescription medications, the doctor name and student name must also show. A parent or guardian must hand deliver the medication to a Highlands Center staff person at the start of the program.

Basic medical care is administered for minor scratches and/or bites and stings. Listed below are common Over the counter (OTC) supplies that we include in our first aid kits. Please mark any that you do NOT want administered to your child.

I attest that my camper’s immunizations required for school are up to date.

Please list any camp activities your child should avoid for health or medical reasons. Include the specific condition and any limitations or precautions we should follow to keep them safe.

Additional comments:

The enrollment and emergency information on this form was provided by:

First NameLast Name

I hereby give permission for my child to participate in all Highlands Center program activities. I understand that my child will be outside for most of the day exploring the forest, creek and other ecosystems of the Highlands Center and that participation in these activities involves inherent risks of physical injury or loss of personal property.
I understand that The Highlands Center will keep camper medical information confidential. The Highlands Center staff will review the information to assess if requested accommodations are reasonable and do not alter the services provided by the program. ‘
I understand that no part of the program fee will be refunded in the event of dismissal or withdrawal due to illness, behavioral incidences or unexpected family obligations.
In the event that The Highlands Center is unable to reach a parent/guardian or emergency contact by phone while the camper is at The Highlands Center, I hereby authorize The Highlands Center staff or medical personnel to take emergency measures as needed.

Signature

Medical Form

Medical Information