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CASEY FARM DAY CAMP Health Form, Medical Waiver and Release
The following information must be completed by the parent/legal guardian of the minor/camper
Form must be returned prior to the first day of camp.
Completed form is necessary for attendance.
All records remain private.
If any changes occur at anytime, you must inform the program coordinator
Name of Participant ________________________________________________________________
Last First Middle
Female Male Date of Birth: __________ Age as of June 15: ______ Grade entering in fall: _____
Home address __________________________________________________________ Phone (h) _________________
Street address City State Zip
Summer address ________________________________________________________ Phone (s) _________________
(If staying there during program) Street address City State Zip
Custodial parent or guardian ________________________________________________ Relationship _______________
Home address ___________________________________________________________________________
(If differs from above) Street address City State Zip
Phone
(Day)________________________ (Eve)_________________________ (Cell) _________________________
E-mail __________________________________
(Needed for camp communication)
Second parent or guardian _________________________________________________ Relationship _______________
Home address
_____________________________________________________________________________________
(If differs from above) Street address City State Zip
Phone
(Day)________________________ (Eve)_________________________ (Cell) _________________________
E-mail __________________________________
Additional Emergency Contact
Must be completed. Should know the child well and/or can assist us in reaching the guardian.
(Person other than guardians) Please include this person on the Release/Pick Up list on page 4, if local.
Name ___________________________ Phone ______________________
(Cell) _________________________
Relationship______________________ Address ________________________________________________________
Street address City State Zip
Insurance Information
Must be completed.
Is the child covered by health and accident insurance or Rite Care? Yes No
Insurance carrier __________________________ Group # ______________
Insurance ID # _________________________
(or Plan Name) (If have one)
Name of insured ______________________________________ Relationship to participant_______________________
Health Care Provider Name _____________________________________________ Phone ________________________
Name of provider's practice__________________________ Address _________________________________________
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Dietary Restrictions: No known restrictions *Peanuts/Nuts: Due to the public nature of our site we cannot
Check all restrictions that apply. guarantee that any area is 100% peanut/nut free.
No Peanuts* No Tree Nuts* No Dairy No Eggs Vegetarian Kosher No Gluten
No __________________ If needed please provide specific dietary instructions
Allergies: No known allergies
This child is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other ________
1) List what the child is allergic to, 2) the reaction seen, 3) how to manage the reaction and 4) if medications are to be brought
to camp, you must complete page 3.
Health HistoryIf your child has any special conditions, needs or limitations, you must speak with the Program Coordinator prior to
being accepted into the program. Non-disclosure may result in dismissal from the program with no refund.
Has/does the participant: Yes No
1. Had a recent injury, illness or infectious disease?..........
2. Have a chronic or recurring illness/condition?..............
3. Had diabetes or problems with blood sugar control?...
4. Been hospitalized/surgery within past 2 years?............
5. Have frequent headaches?..........................................
6. Ever had a head injury?.................................................
7. Had a seizure?...............................................................
8. Wear eyeglasses, contacts or protective eye wear?..........
9. Had fainting or dizziness? ..............................................
10. Had asthma/wheezing? Note type and severity below.....
11. Have any skin problems (rashes, severe acne)?.............
Yes No
13. Had mononucleosis in the past 12 months?
14. Ever been stung by a bee?.
15..Ever been treated for Lyme Disease?..
16. Ever been treated for ADD or ADHD?
17. Have frequent stomachaches? ....................
18. Have problems with constipation/diarrhea?................
19. Ever been treated for an eating disorder?...........
20. Passed out/had chest pain during or after exercise?..
21. Have frequent bloody nose?.
22.. Ever been treated for emotional or behavioral
difficulties...................................
Explain any “yes” answers, noting the number of the question.
To better serve your child
,
1. Please share any information about his/her behavior, physical, emotional or mental health about which we should be aware. These may include
shyness, socialization difficulties, issues with stress, learning style, etc.
2. Please list strategies used to manage the concern and/or to enhance your child's ability to be more successful and happier while with us.
When your child is upset, how do you calm him/her down?
Activity Restrictions
Activities are similar to those described in the brochure and/or within information packets sent home.
Please inform us of any restrictions that might limit your child's participation. In addition you must speak with the Program Coordinator
regarding the issue.
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At-Home Medications Please list the condition and medications taken at home (Example: Hay fever-Claritin).
No medications taken on a routine basis.
Taken Daily:__________________________________________________
Taken Seasonally:_______________________________________________
As needed:__________________________________________________________
At-Camp Medications
Historic New England Staff do not provide or administer any medications to your camper.
Any medication must be administered by the legal guardian before or after the program.
If medications are needed during the camp program they must be listed below.
During camp medications must be administered by the child under the supervision of Historic New England Staff.
Parent/Legal Guardian must supply any and all medications.
Expired medications will not be allowed at the program site.
All medications must be approved by a healthcare consultant/physician
Prescription/Over-the-counter medications
must be in their original containers bearing the pharmacy label and have specific
instructions for use (child’s name, dosage, # pills inside, prescribing practitioner, pharmacy name & address, filler's initials, serial #). Over
the counter medications must be in original container and labeled with the participant's name and dose.
#1 _______________________________________ Amount/dose given_____________ Time/when it is given ____________
Reason for taking ________________________________ How it is given: Inhaled By mouth Other:_______
#2 _______________________________________ Amount/dose given_____________ Time/when it is given ____________
Reason for taking ________________________________ How it is given: Inhaled By mouth Other:_______
#3 _______________________________________ Amount/dose given_____________ Time/when it is given _____________
Reason for taking ________________________________ How it is given: Inhaled By mouth Other:______
Asthma Emergency Medication1) List each medication separately above. 2) You must provide the pharmacy labels!
3) Sign the relevant statement below.
My child does not need to have the inhaler with him/her at all times. The medication may be stored in the
medication box
in the office. Parent/Legal Guardian's Signature__________________________
My child should have the medication/s with him/her at all times in the campers backpack. Note: Camp staff must monitor
each dose. Parent/Legal Guardian's Signature__________________________
My child will bring a: nebulizer spacer
Allergy Emergency Medications1) List each medication separately above. 2) You must provide the pharmacy labels!
3) Sign the relevant statement below. 4) Two Epipens should be provided.
5) Your child must be trained in the use of the Epipen.
Check which medication/s:
Benadryl, Epipen Other: ___________________________________________
My child does not need to have the medication/s with him/her at all times. The medication may be stored in the
medication box in the office. Parent /Legal Guardian's Signature_________________________
My child should have the medication/s with him/her at all times in the camper backpack. Note: Camp staff must monitor
each dose. Parent/Legal Guardian's Signature _________________________
If an Epipen is prescribed, does the child recognize the onset of an allergic reaction so as to notify staff upon the
occurrence of these symptoms? Yes No
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Release / Pick Up Name of Child: ________________________________
In case of a request for the release of the child to a person not listed below, the child will remain with staff until you have been
contacted and have given us permission to release him/her.
Pick up people need to bring a photo ID.
To make additions to this list, the guardian may send a signed note.
If there are specific people your child may not be released to, as an extra precaution, please inform the camp in writing.
Give first and last names (John/Susan Lee, not “the Lees”).
My child may be released to the following people (include carpool drivers and those to pick up in an emergency):
1. Name: ____________________________________________________ Relationship: 1
st Parent/Guardian
2. Name: ____________________________________________________ Relationship: 2
nd Parent/Guardian
3. Name: ____________________________________________________ Relationship: _________________
Phone
(Day)_______________________ (Eve)____________________ (Cell) ________________________
4. Name: ____________________________________________________ Relationship: _________________
Phone
(Day)_______________________ (Eve)____________________ (Cell) ________________________
5. Name: ____________________________________________________ Relationship: _________________
Phone
(Day)_______________________ (Eve)___________________ (Cell) ________________________
Medical Waiver and Authorization Agreement to these terms is a required for participation.
1) Medical release:
This Health History is correct and complete as far as I know. I hereby give permission to Historic New England staff who
are trained in first aid to administer minor treatments and seek emergency medical treatment for my child named above. I
agree to the release of any records necessary for treatment, referral, billing or insurance purposes. I give permission to
Historic New England staff to arrange necessary related transportation for my child named above. In case of a medical
emergency, every reasonable effort will be made to contact me. In the event that I cannot be reached, I hereby give my
permission for the medical personnel selected by Historic New England to secure and administer medical treatment
including to hospitalize, order and administer medications and anesthesia, perform X-rays, special procedures, or surgery,
if deemed medically necessary for my child named above, for which charges I shall be responsible and agree to pay.
2) Medications:
I authorize the “At-Camp Medications” listed above to be administered by my child under the supervision of Historic
New England staff, I understand that all medications, prescribed and over-the-counter, must be in their original containers
and be labeled with specific instructions, including the person's name and dosage, and that the pharmacy label must be on
all prescribed medications. I understand that in no circumstances that Historic New England’s Staff can administer any
medication to your child.
3) Insurance:
I certify that the participant herein described is covered by health and accident insurance or Medicaid and that the policy
information given on page 1 is correct.
4) Release/Pick Up:
I understand the Release Policy as described in the Information Packet and authorize Historic New England to release my
child to the persons and/or method listed above.
I, the parent/legal guardian of the participant, have read, understood, and agree to the above.
1.
________________________________ _________________________________ ______
Parent/Legal Guardian’s Signature Printed Name Date
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Name of Child_________________________
Agreement of Terms
Program:
I give permission for my child to participate in all program activities similar to those described in the camp brochure or
information packet. I understand that Historic New England reserves the right to change program activities or instructors
and cancel programs should Historic New England decide in its sole judgment that it is necessary and appropriate to do so.
Expectations/Dismissal:
I have informed appropriate Historic New England’s staff of any limitations my child has and agree to abide by Historic
New England’s sole judgment as to whether or not the needs of my child can be accommodated. I understand that my
child must follow the stated behavior expectations and safety rules and that Historic New England reserves the right to
dismiss any child whose behavior in its judgment interferes with the rights and safety of others or consistently disrupts
group dynamics and/or activities. In such cases no refunds will be given.
Sun and Bugs:
I understand that outdoor exploration is an integral part of Historic New England’s Casey Farm Camp programs and my
child will, among other things, be exposed to sun, ticks and insects. I understand that it is my responsibility to apply
sunscreen and insect repellent to my child prior to bringing him/her to the program. I hereby give permission for Historic
New England staff to assist my child with the application of sunscreen and/or insect repellent. I understand that some ticks
may transmit disease after being attached for over 24 hours and it is my responsibility to do a thorough body check of my
child every day and to remove any ticks that may become attached. I understand that participants in programs will be given
instructions on how to do self-checks and be reminded by staff to do so.
Payment, Cancellation and Refund:
I understand and agree to the payment, cancellation, refund, and late fee policies as described in the camp brochure,
confirmation letter or information packet I have read, understand and agree to abide by the terms and policies listed above
as well as those found in the camp brochure or information packet.
2.
________________________________ _______ __________________________ ______ _______________
Parent/Legal Guardian’s Signature Printed Name Date
Audio/Visual Image Release
Historic New England uses images and sounds of children and staff participating in programs as a way of documenting the
enjoyable and educational experiences they have while exploring our sites. Historic New England will not identify my
child, or will identify my child only by first name and program, unless I give specific written permission to do otherwise.
In consideration of the above, I hereby consent to Historic New England to;
(1) Photographing, filming, and video/audio taping my child.
(2) Using and displaying images and sounds of my child in Historic New England’s websites, archives, and promotional or
informational material, including, but not limited to, newsletters, brochures, advertisements, and newspaper articles, and I
hereby waive and release on behalf of my child any rights of compensation for, or ownership of, such images and/or
sounds of my child. I have read this media release and agree to its terms and conditions.
3.
________________________________ _______ __________________________ ______ _______________
Parent/Legal Guardian’s Signature Printed Name Date
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Name of Child_________________________
Acknowledgement of Risk
and
Assumption of Personal Responsibility
Historic New England staff members make every effort to conduct safe programs, to orient and
support children, and to inform families of inherent risks. Some activities may involve risks that
children do not routinely encounter at home. Risk management is an essential element of all the
activities that we offer. While we anticipate that these efforts will ensure the wellbeing of each
child, we are also aware that it is neither possible to foresee every contingency nor to eliminate all
risk. I understand that program activities may include, but are not limited to: hiking on uneven
terrain, playing active games, swimming, participating in activities near water and farm equipment,
and other outdoor activities as well as making candles and being near program animals. Other risks
may be inherent in program activities such as the hay ride. I acknowledge that such risks exist, and I
hereby agree on behalf of my child to assume such risks. Further, on behalf of my child, I hereby
release and forever discharge, and agree not to sue, and agree to indemnify and hold harmless,
Historic New England Society, and its officers, directors, employees and volunteers and each of
them, from and against any and all liabilities and obligations of every kind and description, which I
shall or may have against them or any one or more of them arising out of, or in connection with, my
child’s participation in the Historic New England Camp program and its activities, including, but
not limited to, for any personal injury that my child may suffer while participating in the New
England Camp program and its activities, excepting in the case of gross negligence. I understand
and agree on behalf of my child that my child shares the responsibility for safety during New
England Camp program activities, and I personally assume on behalf of my child that responsibility.
I understand and certify that my child’s participation in the New England Camp program and its
activities is completely voluntary, and that I have become familiar with the program activities in
which my child may participate as described in the Agreement of Terms, camp brochure or
information packet.
4.
________________________________ _________________________________ ______
Parent/Legal Guardian’s Signature Printed Name Date
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