INDIAN HILLS 4-H CAMP PERMISSION FORM.

This form must be completed for each participant by the parents/guardians of minors. This information will be kept confidential and used only for the welfare of the participant. Please print clearly.

Participant Information

Date______

Please Circle: Male Female Age______Date of Birth______

Name: Last______First:______MI______

Address:

______

(Street) (City) (State) (Zip)

Home Phone______Cell Phone:______

Email Address:______

In Case of Emergency Contact:

Parent/Guardian

Name______Physcians Name:______

Phone:______Phone:______

Cell Phone:______Dentists Name:______

Phone:______

Other Contact______

Phone______

Instructions for Medications

1. All prescription drugsMUSTbe carried in the container in which they were issued ( with medical orders and physicians name intact),and given to the nurse/health director. Others will not be accepted.

2. If you need over the counter medications not listed below, they must be in original container and must be stored under lock and key by the nurse/health director or a responsible adult during your stay.

CHECK MEDICATIONS BELOW, THAT PARTICIPANT MAY RECEIVE IF DEEMED NECESSARY:

Non aspirin pain medication / Acetaminophen/Tylenol / Laxatives
Dramamine / antiseptics / Diarrhea medication
Coriciden d / Robitussin cough syrup / Adrenalin

Parent/ Guardian Release

______has my permission to participate in the Indian Hills program and activities (with the exception of those restricted activities listed on other form). I understand participants will be supervised. I give permission to Indian Hills 4-H Camp to use photographs, voice and video images of the participant named above and photographs , voice, and video images of any of the activities in which the participant is involved in. I understand that Indian Hills 4-H Camp Board of directors, Staff and volunteers are not responsible in the event of accidental injury or illness, nor for the compounded injury or illness to the participants present medical conditions listed. I further understand in case of serious injury or illness I will be notified. If I cannot be contacted, I give permission to transport the participant to a local medical facility and the attending physician to hospitalize, secure proper treatment, and to order injection, anesthesia, or surgery for the participant named above.

Parent/Guardian Signature______Date______

List Approximate Date If Participant Has Had Or Been Exposed to:

Chicken Pox______Tuberculosis______Measles______Mumps______

Whooping Cough______Scarlet Fever______Tetanus Immunization______

Operations or Serious injuries requiring medical treatment______

Circle Below if Participant is subject to or have experienced

Headaches / Fainting / Heart Trouble / Frequent Colds
Constipation / Convulsions / Frequent Sore Throat / Kidney Trouble
Athletes Foot / Sinusitis / Bed Wetting / Sleep Walking
Ear Infection / Epileptic Seizures / Home Sickness / Bronchitis
Cramps / Diarrhea / Asthma / Other please specify
Nose Bleeds / Heat Related Illness

Check If Participant is Allergic to:

  • Foods Specify______
  • Medications: Prescription or non- prescription drugs______
  • Poison Ivy, Oak, Or Sumac Poisoning______
  • Bee or Insect Sting______

List the Form of Prescribed treatment for each allergy______

LIST ALL PRESENT MEDICAL AND ALLERGIC CONDITIONS (Contact lens, Braces, Diabetes, etc.) which require medication, treatment, or special restrictions or consideration in participation.

Conditions:______

Medications:______

______

SPECIFY ACTIVITY RESTRICTIONS:______

Immunization Record

Please record the date (month & year) of basic immunizations and most recent booster doses or you may attach a copy of Immunization record.

Vaccines / Year of Immunization / Year of last Booster
Diphtheria
Whooping Cough DPT
Tetanus or
Tetanus
Diphtheria
Tetanus
Oral Polio (TOPV)
Injectable Polio
Measles, Mumps, Rubella (hard measles, red measles, Rubella, German Measles)
Tuberculin Test Given
Hemophilus influenza (HIB)
Other

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