Rolling Acres

Outdoor Summer Camp

Enjoying the great outdoors.

DayCampHealthFormandWaiverInstructions

ThankyouforselectingaRolling Acres Outdoor Summer Camp foryourcamper.Weappreciateyoursupporttohelpyoungpeoplegain an appreciation for the nature around them!

CompletethefollowingformsafteryouhavereceivedconfirmationfromRolling Acresthatyourcamperhasbeenacceptedintotheprogram.Thecampwillsendyouaregistrationconfirmationandadditionalinformationonceyourregistrationhasbeenprocessed.Pleasereviewthe camp’s website ( for payment, forms and our refund/cancellation policy

PleasecontacttheCampDirectortoday:

Ifyourcamperhasspecialconditions,needs,orlimitations.YoumustspeakwiththeCamp Administrator todeterminewhetheryourcampercanbeaccommodatedatcampbeforethecamperisacceptedintotheprogram.Non-disclosuremayresultindismissalwithoutrefund.

  • IfyourcamperdoesnothavehealthandaccidentinsurancevalidintheU.S.
  • Ifyourfamily’sreligiousbeliefsdonotpermitphysicalexamsand/orimmunizations.TheCampAdministrator canprovideyouwithouremergencytreatmentpolicyandimmunization/physicalexamwaiver.
  • IfyouhaveconcernsregardingtheAgreementofTerms,ImageRelease,orAcknowledgmentofRisk.

AnewsetofCampHealthFormsandWaiversmustbecompletedforeachcamperpriortoeachcampseason.Rolling Acres Outdoor Summer Camp requiresthateachcampermusthavean original copyofthesesignedformsonsite.Pleasenoteonanycopies.

Youmaycompletetheformsonyourcomputer,buttheymustbeprinted,signed,andmailedordeliveredtothecamp,alongwiththerecordofthecamper’sphysicalandimmunizations(includingthedateofthemostrecenttetanusshot).Keepacopyoftheformsforyourfiles.

Rolling Acres

Outdoor Summer Camp

DayCampHealthHistory

Checkyourcampconfirmationfortheformsdeadline!

Instructions:Aparent/guardian mustcompletethisformforthecamper.Attach anyadditionalneededinformation, includingacopyofthecamper’simmunizationandphysicalexamrecords,asthma/allergyactionplans,healthinsurancecard, orotherneededinformation.Keepacopyofthecompletedformforyourrecords.Ifyourcamperhasanyspecialconditions,needs,orlimitations,youmustspeakwiththeCampAdministratorbeforebeingacceptedintothecampprogram.Non-disclosuremayresultindismissalfromtheprogramwithoutrefund.

CamperInformation:

Name:

FemaleMaleOther

LastFirstMiddleNickname

BirthDate:

Month/Day/Year

AgeasofJune15:

Gradeenteringinfall:

Camperhomeaddress:

StreetAddressCityStateZipCode

Localorsummeraddressduringcamp,ifdifferent:

StreetAddressCityStateZipCode

HealthCareProvider:

PrimaryCareProvider:

Phone:

Nameofpractice:Address:

Required:Includeacopyofthecamper’simmunizationrecordandproofofphysicalexamwithinthe24monthsbeforecamp.Thedateofthelasttetanusimmunizationisrequired.

MedicalInsurance:Thiscamperiscoveredbyhealth/accidentinsuranceorMedicaid.YesNo

Youmustprovidehealthinsuranceinformationbelow.Forcamperswithouthealthinsurance,contacttheCamptoday!InsuranceCarrier/PlanName: PolicyNumber: SubscriberName: Relationshiptocamper:

Restrictions:Campactivitiesaresimilartothosedescribedon the websiteandcampbrochure.

IhavereviewedtheCamp’sprogram/activitiesandfeelthecampercanparticipatewithoutrestrictions.

IhavereviewedtheCamp’sprogram/activitiesandfeelthecampercanparticipatewiththefollowingrestrictionsoradaptations.(PleasedescribebelowandspeakwiththeCamp Administrator.)

Allergies:Noknownallergies.

Thiscamperisallergicto:FoodMedicinetheenvironment(hayfever,insects,etc.)Other(Describebelowtheallergyandthereactionseen.)

Ifacamperhasananaphylacticallergy,includeacopyofthecamper’sallergyactionplan.Wecannotguaranteethatanyareaatcampisallergen-free.

DietandNutrition:Thiscampereatsaregulardiet.Thiscamperhasspecialfoodneeds.(Describebelow.)

GeneralHealthHistory:Check“Yes”or“No”foreachstatement.Explain“Yes”answersbelow.Has/doesthecamper:

1.Beenhospitalized/hadsurgeryinpast2yrs?

2.Haverecurrent/chronicillness(es)?

3.Hadarecentinjury/illness/infection?

4.Everhadaheadinjuryorconcussion?

5.Haveasthma*/wheezing/shortnessofbreath?

6.Havediabetes?

YesNo14.Passedout/hadchestpainduringexercise?

YesNo15.Hadmononucleosisduringthepastyear?

YesNo16.Everhadback/jointproblems?

YesNo17.EverbeentreatedforLymeDisease?

YesNo18.Everbeenstungbyabee?

YesNo19.Iffemaleandofage,haveproblemswith

YesNo

YesNo

YesNo

YesNo

YesNo

7.Hadseizures?

YesNo

periods/menstruation?NotApplicable

YesNo

8.Havesevereorfrequentheadaches?

9.Wearglasses/contacts/protectiveeyewear?

10.Hadfaintingordizziness?

11.Havefrequentbloodynose?

YesNo20.Haveproblemsfallingasleep/sleepwalking?

YesNo21.Haveacurrenthistoryofbedwetting?

YesNo22.Haveanyskinproblems?

YesNo23.Haveproblemswithdiarrhea,constipation,

YesNo

YesNo

YesNo

12.Havemotionsickness?

YesNo

orfrequentstomachaches?

YesNo

13.Haveaphobia?(notetype/severitybelow)

YesNo24.TraveledoutsidetheU.S.inthepastyear?

YesNo

Explain“Yes”answersinthespacebelow,notingthenumberofeachquestionrequiringaresponse.FortraveloutsidetheU.S.,giveplacesvisitedanddatesoftravel.Attachadditionalpagesifneeded.

*Ifacamperhasasthma,includeacopyofthecamper’sasthmaactionplan.

Mental,Emotional,andSocialHealthHistory:Check“Yes”or“No”foreachstatement.Explain“Yes”answersbelow.Has/doesthecamper:

1.Everbeendiagnosedwithattentiondeficitdisorder(ADD)orattentiondeficithyperactivitydisorder(ADHD)?

2.Everbeentreatedforemotional/behavioraldifficulties,self-harm,oraneatingdisorder?

3.Everhaveneedforanaideatschool?

4.Usedanindividualizededucationplan(IEP)duringthepreviousschoolyear?

5.SpeakaprimarylanguageotherthanEnglish?

YesNo

YesNo

YesNo

YesNo

YesNo

Explain“Yes”answersinthespacebelow,notingthenumberofeachquestionrequiringaresponse.AttachadditionalpagesorcontacttheCampDirectortoprovideadditionalinformationifneeded.

Tobettercareforyourcamper:Provideanyadditionalinformationaboutthecamper’sbehaviororphysical,mental,emotional,andsocialhealththatyouthinkimportantorthatmayaffectthecamper’sabilitytoparticipateintheCampprogram(shyness,learningstyle,etc.)Listanystrategiesusedtomanagetheconcernorenhancethecamper’sability.

Medicationsathome:Thiscamperdoesnottakemedicationsregularlyathome.(Listat-campmedicationsonp.3.)

Thiscampertakesthefollowingmedicationsathome.(Pleasedescribethemedicationandconditionbelow.)

Daily:Seasonally:Other:

MedicationsAtCamp:Thiscamperwillnotbringanymedicationstocamp.

Includeanymedicationthatthecampermayneedtotakeatcamp,includingvitamins,Lactaid,etc.Attachadditionalpagesifneeded.Thecamper’sparent/guardianmustsupplythesemedications,labeledwiththecamper’sname,unexpiredandinoriginalcontainers,andbearingspecificdirectionsforadministering.Prescriptionmedicationsmusthavethefullpharmacylabel.Contactthecampadministratorifacampertakesmedicationformentalhealthandthemedicationordosehaschangedwithinthethreemonthspriortocamp.

Thiscamperwillbringthefollowingmedicationstocamp:

Nameof
Medication / Amountor
dose / Howitisgiven
(ex:bymouth) / Whenitisgiven / Date
Started / Reasonfortaking
Time:
Asneeded
Time:
Asneeded
Time:
Asneeded
Time:
Asneeded

AsthmaEmergencyMedications:Thiscamperdoesnothaveasthmaemergencymedications.

Includeacopyofthecamper’sasthmaactionplan.Contactthecampdirectorifyouhaveanyquestions.

NameofMedication / Amount/dose / Route(ex:inhaled) / Whenitisgiven

Thiscamperneedsasthmamedicationonlyforrespiratoryillnessandwillnotbringittocampunlessaparent/guardiannotifiesthecamp.

Thiscamperwillbringasthmamedicationtocampbutdoesnotneedtohaveitnearbyatalltimes.Themedicationmaybestoredinthemedicationbox(MB)intheoffice.Parent/GuardianSignature: MB

Thiscamperwillbringasthmamedicationtocampandshouldhaveitnearbyatalltimesinthecamppack(P).Campstaffmustmonitoreachdose. Parent/GuardianSignature: P

Thiscamperwillalsobring:nebulizerspacer

AllergyEmergencyMedications:Thiscamperdoesnothaveallergyemergencymedications.

Includeacopyofthecamper’sallergyactionplan.Contactthecampdirectorifyouhaveanyquestions.ProvidetwoEpiPensbearingtheoriginalpharmacylabels.

NameofMedication / Amount/dose / Route(ex:injected) / Whenitisgiven
Benedryl/
diphenhydramine
EpiPen/
EpiPenJr.

Thiscamperwillbringallergyemergencymedicationbutdoesnotneedtohaveitnearbyatalltimes.Themedicationmaybestoredinthemedicationbox(MB)intheoffice.Parent/GuardianSignature: MB

Thiscamperwillbringallergyemergencymedicationandshouldhaveitnearbyatalltimesinthecamppack(P).Campstaffmustmonitoreachdose. Parent/GuardianSignature: P

Thiscamperhasbeentrainedtoadministerhis/herownEpiPen.(Requiredforage5+)

Thiscamperrecognizestheonsetofanallergicreactionandcannotifyacampstaffmemberifsymptomsoccur.

Thiscamperdoesnotrecognizeandreporttheonsetofanallergicreaction.CalltheCampDirectortoday!

Release/Pick-Up:

Mycampermaybereleasedtothefollowingadults(includingcarpooldriversorthosewhomaypickupinanemergency.)Includefirstandlastnames(John/SusanLee,not“theLees”).

1.Name:Relationship:CustodialParent/Guardian

2.Name:Relationship:SecondParent/Guardian

3.Name:Relationship:_

PhoneDay:

Evening:

Cell:

4.Name:Relationship:

PhoneDay:

Evening:

Cell:

5.Name:Relationship:

PhoneDay:

Evening:

Cell:

6.Othermeansofdismissalpermitted(walking,bicycling,taxi,etc.):

Theparent/guardianmaysendasignednotetomakechangestothislist.PeoplepickingupcampersmustbringaphotoID.Ifapersonnotlistedabovearrivestopickupacamper,thecamperwillremainwithcampstaffuntiltheparent/guardianhasbeencontactedandhasgivenpermissionfortherelease.Iftherearespecificpeopletowhomthecampermaynotbereleased,pleaseinformthecampinwriting.

MedicalWaiverandAuthorization(agreementisrequiredforparticipation):

MedicalRelease:Thishealthhistoryiscorrectandaccuratelyreflectstheknownhealthstatusofthenamedcamper.Thecamperdescribedhaspermissiontoparticipateinallcampactivitiesexceptasnotedbymeand/oranexaminingphysician.Igivepermissiontocampstafftoprovideroutinehealthcare;toadministerprescribedorover-the-countermedicationsasdescribed;andtoprovideorobtainemergencycareandtransportationforthecamperifneeded.Igivepermissiontothephysicianselectedbythecamptoorderx-rays,tests,andtreatmentrelatedtothehealthofmychildbothforroutinehealthcareandinemergencysituations.IfIcannotbereachedinanemergency,Igivemypermissiontothephysiciantohospitalize,securepropertreatmentfor,andorderandadministermedication,injection,anesthesia,X-rays,specialprocedures,orsurgeryforthischild,ifdeemedmedicallynecessary.IunderstandthatIamresponsibleforthecostofanymedicalcareorprescriptionsmychildrequires.Iagreetothereleaseofanyrecordsnecessaryfortreatment,referral,billing,orinsurancepurposes.Iunderstandthatinformationonthisformwillbesharedona"needtoknow"basiswithcampstaff.

Medications:PursuanttoMassachusettslawandRolling Acrespolicy,IauthorizeRolling Acre’sdesignatedhealthcarestafftoadministeraslistedaboveMedicationsAtCampandAsthmaorAllergyEmergencyMedications,asdirected,tomychildforwhomitwasprescribed.Iunderstandthatallmedicationsatcampmustbeapprovedbythecamp’soff-sitehealthcareconsultant,seenandcheckedbythecamp’shealthsupervisor,andeachdosemonitoredbyacampstaffmember.Iunderstandthatallmedicationsmustbeintheiroriginalcontainers,unexpired,andlabeledwithspecificinstructions,includingthechild’snameanddosage,andthatanyprescriptionmedicationsmustincludethefullpharmacylabel.

Insurance:IcertifythatthenamedcamperiscoveredbyhealthandaccidentinsuranceorMedicaidandthatthepolicyinformationgiveniscorrect

Release/Pick-up:IunderstandthereleasepolicyasdescribedandauthorizeRolling Acres Outdoor Summer Camptoreleasemychildtothepeople/methodslistedabove.

I,theparent/legalguardianofthenamedcamper,haveread,understood,andagreetotheabove.

SignatureofCustodialParent/Guardian:

Date:

PrintName:

Relationshiptocamper:

Rolling Acres

Outdoor Summer Camp

DayCampAgreementofTerms

Checkyourcampconfirmationfortheformsdeadline!

CamperName:

LastFirstMiddle

Program:Igivepermissionformychildtoparticipateinallcampprogramactivitiessimilartothosedescribedon the camp’s website, andcampbrochure.IunderstandthatRolling Acresreservestherighttochangeprogramactivitiesorinstructorsandcancelprograms,shouldRolling Acresdecideinitssolejudgmentthatitisnecessaryandappropriatetodoso.

Expectations/Dismissal:IhaveinformedtheCampAdministratorandotherappropriateRolling Acresstaffofanylimitationstomychild’sparticipationandagreetoabidebyRolling Acre’ssolejudgmentastowhethermychildcanbeaccommodatedinthecampprogram.Iunderstandthatfailingtodiscloseanyphysical,emotional,orbehavioralneedsorconditionsmayresultinthechild’sdismissalfromtheprogramwithoutrefund.IunderstandthatmychildmustfollowthestatedbehaviorexpectationsandsafetyrulesandthatRolling Acresreservestherightinitssolejudgmenttodismisswithoutrefundanychildwhosebehaviorinterfereswiththerightsandsafetyofothersorconsistentlydisruptsgroupdynamicsoractivities.

SunandBugs:IunderstandthatoutdoorexplorationisanintegralpartofRolling Acresprogramsandmychildwillbeexposedtorisksincludingbutnotlimitedtosun,ticks,andinsects.Iunderstandthatitismyresponsibilitytoapplysunscreenandinsectrepellanttomychildbeforebringinghim/hertocampeachday.IgivepermissiontoRolling Acresstafftoassistmychildinre-applyingsunscreen,insectrepellant,andtopicalanti-itchcream.Iunderstandthatsometicksmaytransmitdiseaseafterbeingattachedforover24hours,anditismyresponsibilitytocheckmychild’sbodythoroughlyeverydayandtoremoveanyticksthatmaybecomeattached.Iamresponsibletodoacompletecheckuponmychild’sreturnhome.

Payment,Cancellation,andRefund:Iunderstandandagreetothepayment,cancellation,refund,andlatefeepoliciesasdescribedinthecamp’swebsite, andbrochure.

Ihavereadandagreetoabidebythetermsandpolicieslistedaboveandthosefoundonthecamp’s website, brochure,confirmationletter,orinformationpacket.

I,theparent/legalguardianofthenamedcamper,haveread,understood,andagreetotheabove.

SignatureofCustodialParent/Guardian:

Date:

PrintName:

Relationshiptocamper:

DayCampAudio/VisualImageRelease

Rolling Acresusesimagesandsoundsofchildrenandstaffparticipatinginprogramsasawayofdocumentingtheenjoyableandeducationalexperiencestheyhavewhileexploringnature.Rolling Acreswillnotidentifymychild,orwillidentifymychildonlybyfirstnameandprogram,unlessIgivespecificwrittenpermissiontodootherwise.

Inconsiderationoftheabove,IherebyconsenttoRolling Acres(1)photographing,filming,andvideo-tapingmychild,and(2)usinganddisplayingimagesandsoundsofmychildinRolling Acre’swebsites,archives,andpromotionalorinformationmaterial,includingbutnotlimitedtonewsletters,brochures,advertisements,andnewspaperarticles,andIherebywaiveandreleaseonbehalfofmychildanyrightsofcompensationfor,orownershipof,suchimagesand/orsoundsofmychild.

Ihavereadthismediareleaseandagreetoitstermsandconditions.

SignatureofCustodialParent/Guardian:

Date:

PrintName:

Relationshiptocamper:

Waivers–Page1of2

Rolling Acres

Outdoor Summer Camp

DayCampAcknowledgementofRiskandAssumptionofPersonalResponsibility

CamperName:

LastFirstMiddle

Rolling Acresstaffmembersmakeeveryefforttoconductsafeprograms,toorientandsupportchildren,andtoinformfamiliesofinherentrisks.Someactivitiesmayinvolverisksthatchildrendonotroutinelyencounterathome.Riskmanagementisanessentialelementofalltheactivitiesoffered.Whileweanticipatethattheseeffortswillensurethewellbeingofeachchild,wearealsoawarethatitisneitherpossibletoforeseeeverycontingencynortoeliminateall risk.

Iunderstandthatprogramactivitiesmayinclude,butarenotlimitedto:walkingonuneventerrain,playingactivegames,participatinginactivitieswithwater, gardening andjumping pillow.Thecampwebsite,brochure,orinformationpacketwillinformyouofspecialactivities.Otherrisksmaybeinherentinprogramactivities.

Iacknowledgethatsuchrisksexist,andIherebyagreeonbehalfofmychildtoassumesuchrisks.Further,onbehalfofmychild,Iherebyreleaseandforeverdischarge,andagreenottosue,andagreetoindemnifyandholdharmlessRolling Acres Outdoor Summer Campanditsofficers,directors,employees,andvolunteersandeachofthem,fromandagainstanyandallliabilitiesandobligationsofeverykindanddescription,whichIshallormayhaveagainstthemoranyoneormoreofthemarisingoutof,orinconnectionwith,mychild’sparticipationintheRolling Acresprogramandactivities,including,butnotlimitedto,foranypersonalinjurythatmychildmaysufferwhileparticipatingintheRolling Acresprogramandactivities,exceptinginthecaseofgrossnegligence.

IunderstandandagreeonbehalfofmychildthatmychildsharestheresponsibilityforsafetyduringRolling Acresprogramsandactivities,andIpersonallyassumeonbehalfofmychildthatresponsibility.

Iunderstandandcertifythatmychild’sparticipationintheRolling Acresprogramanditsactivitiesiscompletelyvoluntary,andthatIhavebecomefamiliarwiththeprogramactivitiesinwhichmychildmayparticipate,asdescribedintheAgreementofTermsorcampwebsite,brochure,orinformationpacket.

SignatureofCustodialParent/Guardian:

Date:

PrintName:

Relationshiptocamper:

Waivers–Page2of2

Rolling Acres

Outdoor Summer Camp

DayCampHealthCareRecord

Checkyourcampconfirmationfortheformsdeadline!

TotheParent/Guardian:Ifyourhealthcareproviderhasgivenyouaformrecordingthemostrecentphysicalexamandallrequiredimmunizations,sendacopytothecampanddonotcompleteandreturnthispage.

Ifyourhealthcareproviderhasnotgivenyouaformrecordingthemostrecentphysicalandallrequiredimmunizations,completetheCamperInformationbelowandsendthispagetotheprovider’sofficetocomplete.Itisyourresponsibilitytoreturnthiscompletedpagetothecamp,priortotheformsdeadline.ContacttheCampAdministratorforawaiverthatmustbecompletedifthecamperhasnothadaphysicalexamorbeenfullyimmunizedforreligiousreasons.Keepacopyofthiscompletedformforyourrecords.

CamperInformation:

Name:FemaleMaleOtherBirthDate:

FirstMiddleLastMonth/Day/YearParent/GuardianName: Parent/GuardianPhone: Tothelicensedmedicalprovider:Completethisformforthecampernamedabove.Attachanyadditionalneededinformation.Acopyofapreviouslycompletedformfromayearlyphysical,orsimilar,maybesubmittedinplaceofthisform.

Physicalexamdonetoday: Yes No(If“No”,dateoflastphysical:)

Month/Day/Year

Weight:lbsHeight:_ft_in.BloodPressure:/

Allergies:Noknownallergies.

Thiscamperisallergicto(listall):FoodMedicinetheenvironment(hayfever,insectstings,etc.)OtherDescribepreviousreactions:

Ifacamperhasananaphylacticallergyorasthma,includeacopyofthecamper’sallergyand/orasthmaactionplan(s).

DietandNutrition:Thiscampereatsaregulardiet.

Thiscamperhasamedicallyprescribeddietordietaryrestrictions.Pleasedescribe:

Medications:Thiscamperdoesnottakeanymedications.

Thiscampertakesthefollowingmedication(s).Describebelow,andincludethemedicationname,dose,frequency,andreasonfortaking.Attachadditionalinformationifneeded.

Willthecamperrequirelimitationsorrestrictionstoactivitywhileatcamp?NoYes

If“Yes”,whatlimitations/restrictionsdoyourecommend?Describebelow.Attachadditionalinformationifneeded.

Additionalinformationforcamphealthcarestaff:

ImmunizationHistory:Providetheday,month,andyearforeachimmunization.Massachusettsrequirementsarelistedbelow.

Serologicproofofimmunityisacceptedinlieuofimmunization.Campersmustmeettherequirementsforthegradetheyareentering,exceptthoseenteringKindergartenmaymeetthePreschoolrequirementsforsummercamp.Immunizationsmustberecordedandsignedbyalicensedmedicalprovider.Thedateofthelasttetanusimmunizationisrequired.

Immunization[Grade(s):#doses] / Dose1 / Dose2 / Dose3 / Dose4 / Dose5/mostrecent
Diphtheria,tetanus,pertussis(DTP,DT,DTaP,Td,orTdaP)
[Pre,1st-6th:4,K:5]
Tetanusbooster(Td,TdaP)[7th-10th:1] / mustbewithinthelast10years
Measles,Mumps,Rubella(MMRorMMRV)[Pre:1,K-12th:2]
Polio(OPVorIPV)[Pre,7th-12th:3,K-6th:4]
HepatitisB[Pre-6th:3]

SignatureofLicensedProvider:

Date:

PrintName:Title:

OfficePhone:

OfficeAddress:

StreetAddressCityStateZipCode

HealthCareRecord–Page1of1