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MEDICAL HISTORY AND EMERGENCY AUTHORIZATIONS

I attest that my child is in good physical and mental health. Any special considerations are indicated below. In case of accident or illness, I hereby give permission that my child may be given emergency treatment and, further, I authorize and consent to the administration of any and all medical, dental, and surgical examinations or operations and treatment or all other related care, including the administration of drugs, tests, anesthesia, and/or blood transfusions to the above named child that may be ordered by the medical care provider in attendance at the facility deemed necessary for medical treatment. I hereby consent to the release of medical report(s) to any medical care provider and consent to the admission of the above-named child to a hospital. I agree to be responsible for any medical expenses incurred on behalf of my child.

Child's Name:

Last
First
Birth Date
Registered for Camp:
MFC2 MFC3 Green Sprouts Green Thumbs Explorers Adventurers
Person who registered child for camp
Parent/Guardian Name
Day Phone
Evening Phone
Cell Phone
Person to Contact in an Emergency:
Name
Relationship
Address
Day Phone
City
Evening Phone
Zip
Alternate Person to Contact in an Emergency:
Name
Relationship
Address
Day Phone
City
Evening Phone
Zip

Doctor's Name:
Medical Insurance Company
Insurance ID Medical Number
Date of child's most recent physical examination
Does your child routinely require Medication? Yes No
If Yes, please give details below under medical concerns.

IMPORTANT: Please describe any special health considerations including, but not limited to, allergies, physical of behavioral conditions that may affect your child's participation in this camp.
Allergies:
My child may have sunscreen applied during the day. Yes No

My child may partake of the tree-nut-free camp snack with no restrictions
(If NO, please provide daily snack for your child.)
Yes No

Medical concerns (medications, past health problems, etc.):


Limitations on activities:
Behaviors of which staff should be aware:
How do you handle this behavior?
Other:
I hereby authorize the following individuals to pick up my child:
Name
Relationship
Address
Day Phone
City
Zip
Evening Phone

Name
Relationship
Address
Day Phone
City
Zip
Evening Phone

Name
Relationship
Address
Day Phone
City
Zip
Evening Phone

Name
Relationship
Address
Day Phone
City
Zip
Evening Phone

NOTE: Written notification by parents or guardian MUST be given for pick-up by someone other than persons listed. Please let us know if there are any issues regarding pick-up/drop-off of which we should be aware (custody disputes, etc.)

CAMPER CODE OF CONDUCT
• Campers will treat their fellow campers, instructors, and volunteers with respect.
• Campers will follow directions and stay with their group.

Please read and discuss these expectations with your child. In the event that a camper does not follow the Code of Conduct, or his or her behavior endangers other campers or interferes with an instructor’s ability to provide programming, the instructor will inform the parent and the Coordinator of Youth Services at pick-up or through a phone call. If a second incident occurs, parents may be asked to accompany their child during camp, or withdraw from camp. Refunds will not be given for behavior-related withdrawals.

I have read and discussed this Code of Conduct with my child. Please check box.

I understand that by completing and submitting this Medical Form via electronic transmission that I acknowledge the above statements and my submission of this form on-line shall substitute for and have the same legal effect as an original form signature.