Camper Info Form | Dragonfly Kayak Tour

HAPPY ORCAS ADVENTURE CAMP

CAMPER INFORMATION & HEALTH HISTORY

Thank you for selecting Happy Orcas Adventure Camp for your young camper! We appreciate your support to help young people learn about and explore the world around them.

Please complete the following forms after you have enrolled your child in camp. Please be assured that all information provided is confidential and will be shared only with camp counselors and director.

Please contact the Camp Director today if any of the following apply:

Your camper has special conditions, needs or limitations. You must speak with the Camp Director to determine whether your camper can be accommodated at camp. Non-disclosure may result in dismissal without refund.
Your camper does not have health and accident insurance valid in the U.S.
Your family’s religious beliefs do not permit physical exams and/or immunizations.
You have concerns regarding the Agreement of Terms, Image Release or Acknowledgement of Risk.

Campers Full Name & Nickname

Campers Preferred Pronouns

Date of birth

Month

Day

Year

Age at time of camp

Height/Weight (for proper PFD sizing)

Grade entering

Which session(s) attending?

Siblings - How many and how old?

Are any siblings attending camp? If so please list their name(s).

Has your child attended camp before? If yes, how was their experience?

Your child's camp experience is very important to us. Please use this space to describe any important details about your child that will help the counselors provide the best support possible.

What are your child's interests, talents, hobbies?

What do you expect your child to gain from their experience at camp?

How well does your child swim?

Non-swimmer

Beginner

Intermediate

Advanced

Describe any behavioral issues that your child's counselor should be made aware of. Also, please list any medications that your child takes that affects their behavior or mood.

What words would you use to describe your child's personality?

Camper Home Address

Local summer address, if different

Custodial Parent/Guardian Name & Relationship to Camper

Day Phone

Evening Phone

Cell Phone

Address, if different

Second Parent/Guardian

Day Phone

Evening Phone

Cell Phone

Address, if different

Additional Emergency Contact (This should be someone the camper knows well and can assist in reaching the guardian)

Relationship to camper

Day Phone

Evening Phone

Cell Phone

Address

Healthcare Provider Information

Primary Care Provider

Name of PCP Practice

PCP Phone

PCP Address

Medical Insurance

Is this camper covered by health/accident insurance or Medicaid?

Yes

Insurance Carrier/Plan Name

Insurance Policy Number

Subscriber Name

Relationship to Camper

Camper Health History

Restrictions: Camp activities are similar to those described on camp website. If more details are required, please contact the Camp Director.

I have reviewed the Camp's programs/activities and feel the camper can participate without restrictions.

I have reviewed the Camp's programs/activities and feel the camper can participate with the following restrictions or adaptations

Please describe and speak with the Camp Director

Allergies

No known allergies

The camper has allergies to

Food

Medicine

The environment (hay fever, insects, etc.)

***If a camper has an anaphylactic allergy, please include a copy of the camper's allergy plan. We cannot guarantee that any area at camp is allergen free.

Allergy Plan (if applicable)

Diet and Nutrition

This camper eats a regular diet

This camper has special food needs (describe below)

Dietary restrictions/needs

General Health History: Check the box for each true statement. Explain checked answers in the form below.

Explain "true" answers in the space below. For travel outside the U.S., give places visited and dates of travel. Attach addition pages if needed. If camper has asthma, include a copy of the camper’s asthma action plan.

Mental, emotional and social health history: Please check the box for each true statement and explain your answers below.

Has/does the camper:

Ever been diagnosed with ADD or ADHD?

Ever been treated for emotional/behavioral difficulties, self-harm or an eating disorder?

Ever had need for an aide at school?

Used an individualized education plan (IEP) during the previous school year?

Speak a primary language other than English?

Please explain all "true" answers.

To better care for your camper please provide any additional information about the camper’s behavior or physical, mental, emotional and social health that you think important or that may affect the camper’s ability to participate in the Camp program.

Please list any medications your child takes regularly at home and include the frequency and dosage.

Please include any medication that the camper may need to take at camp. The camper’s parent/guardian must supply these medications labeled with the camper’s name, unexpired and in original containers, and bearing specific directions for administering.

Asthma Emergency Medications - Please include a copy of the camper's asthmas action plan. Contact the Camp Director if you have any questions. List the name of medication, amount/dose, route (ex. Inhaled) and when it is given.

Please select an applicable statement below:

This camper needs asthma medication only for respiratory illness and will not bring it to camp unless a parent/guardian notifies the camp.

This camper will bring asthma medication to camp but does not need to have it nearby at all times.

This camper will bring asthma medication to camp and should have it nearby at all times. Camp staff must monitor each dose.

This camper will bring a nebulizer.

This camper will bring a spacer.

Allergy Emergency Medication: Please include a copy of the camper’s allergy action plan. Contact the Camp Director if you have any questions. Provide TWO EpiPens bearing the original pharmacy labels.

List the names of medications, amount/dose, route (ex. injected) and when it is given.

Please select all that apply:

This camper will bring allergy emergency medication but does not need to have accessible at all times.

This camper will bring allergy emergency medication. Emergency medications must be immediately accessible to staff at all times during camp activities. Camp staff must monitor each dose.

This camper has been trained to administer his/her own EpiPen.

This camper recognizes the onset of an allergic reaction and can notify a camp staff member if symptoms occur.

Release Pick-up Authorization

My camper may be released to the following adults (including carpool drivers or those who may pick up in an emergency). Include first and last names.

Name/Relationship/Phone

Medical Waiver and Authorization (agreement is required for participation):

Medical Release: This health history is correct and accurately reflects the known health status of the named camper. The camper described has permission to participate in all camp activities except as noted by me and/or an examine physician. I give permission for camp staff to assist with or supervise the administration of medications listed in this form, in accordance with the instructions provided by the parent/guardian. I understand that camp staff will not determine dosage or administer medication outside of these written instructions; and to provide or obtain emergency care and transportation of the camper if needed. I give permission to the physician selected bay the camp to order x- rays, tests, and treatment related to the health of my child both for routine health care and in emergency situations. If I cannot be reached in an emergency’s I give my permission to the physician to hospitalize, secure proper treatment for, and order and administer medication, injection, anesthesia, x-rays, special procedures, or surgery for this child, if deemed medically necessary. I understand that I am responsible for the cost of any medical care or prescriptions my child requires. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. I understand that information on this for will be shared on a “need to know” basis with camp staff.

Medications: I authorize Happy Orcas Adventure Camp staff to assist with or supervise the administration of medications listed above, in accordance with the instructions provided by the parent/guardian. I understand that staff will not determine dosage or administer medication outside of these written instructions. I understand that all medications must be in their original containers, unexpired, and labeled with specific instructions, including the child’s name and dosage, and that any prescription medications must include the full pharmacy label. Over-the-counter medications will only be administered if specifically listed above with clear written instructions. I understand that failure to provide accurate and complete medication information may increase risk and may result in my child being unable to participate. Camp staff reserve the right to decline to administer medication if instructions are unclear or cannot be safely followed.

Insurance: I certify that the named camper is covered by health and accident insurance or Medicaid and that the policy information given is correct.

Release/Pick-up: I understand the release policy as described and authorized Happy Orcas Adventure Camp to release my child to the people/methods listed above.

I, the parent/legal guardian of the named camper, have read, understand, and agree to the above.

Signature of Legal Parent/Guardian

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Print Name

Date

Month

Day

Year