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 familyās religious beliefs do not permit physical exams and/or immunizations.
You have concerns regarding the Agreement of Terms, Image Release or Acknowledgement of Risk.
How well does your child swim?*
Healthcare Provider Information
Is this camper covered by health/accident insurance or Medicaid?*
Restrictions: Camp activities are similar to those described on camp website. If more details are required, please contact the Camp Director.
The camper has allergies to
***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.
General Health History: Check the box for each true statement. Explain checked answers in the form below.
Mental, emotional and social health history: Please check the box for each true statement and explain your answers below.
Please select an applicable statement below:
Allergy Emergency Medication: Please include a copy of the camperās allergy action plan. Contact the Camp Director if you have any questions. Provide TWO EpiPens bearing the original pharmacy labels.
Please select all that apply:
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.
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 to camp staff to provide routine health care; to administer prescribed or other-the-counter medications as described; and too provide or obtain emergency care and transportation fo 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 emergencyās 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 āneed to knowā basis with camp staff.
Medications: I authorize Happy Orcas Adventure Campās designated staff to administer as listed above Medication at Camp and Asthma or Allergy Emergency Medications, as directed, to my child for whom it was prescribed and that each dose will be monitored by a staff member. I understand that all medications must be in their original containers. Unexpired, and labeled with specific instructions, including the childās name and dosage, and that any prescription medications must include the full pharmacy label.
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.