Outdoor Adventure Camp Emergency Medical Authorization And ...

Outdoor Adventure Camp Emergency Medical
Authorization And Health Form
Complete both sides and return before your child’s camp program.
One form per child is required to participate in camp.
To be completed by parent or guardian.
Purpose: Please provide complete information so that the staff can be aware of your child’s needs and provide
appropriate care. Any changes to this form should be submitted to camp personnel upon your child’s arrival in camp.
Camper’s Last Name______________________ First Name________________ DOB ____/____/____ □ Male □ Female
Home Address________________________________________________________ Phone_________________________________
Parent or Guardian 1__________________________________________________ Phone__________________________________
Parent/Guardian 2___________________________________________________ Phone__________________________________
If Parent, Guardian are not available in an emergency, notify:
1___________________________________________________________ Phone_________________________________________
2___________________________________________________________ Phone_________________________________________
Other Person(s) Authorized to pick up your child:
1_______________________________ Relationship: ____________________________ Phone: ____________________________
2_______________________________ Relationship: ____________________________ Phone: ____________________________
Camper’s physician_____________________________________________________ Phone_______________________________
Address_____________________________________________________________________________________________________
Camper’s dentist/orthodontist ___________________________________________ Phone_______________________________
Purpose: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured
while under the Nature Center’s authority, when parents or guardians can not be reached.
Important — Part I or Part II must be completed for camp attendance
Part I, CONSENT GRANTED
I, the undersigned, hereby give permission for my child to participate in all activities (unless otherwise
specified) and assume all risks and hazards incidental to the program. I also hold harmless the Nature Center at
Shaker Lakes, its staff, and appointed assistants. I also understand and agree to abide by any restrictions
placed on my child’s participation in camp activities.
Parent/Guardian Authorizations: This health history and any attached forms are correct and complete as far as
I know, and the person herein described has permission to engage in all camp activities except as noted.
I hereby give permission to the Nature Center at Shaker Lakes to provide and seek emergency medical
treatment and administer prescribed medications by certified staff. I agree to the release of any records
necessary for insurance purposes. I give permission to the staff to arrange necessary related transportation for
me/my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician and
dentist named above to administer treatment, including hospitalization at __________________(named
hospital) or any hospital reasonably accessible, for the camper named above. This authorization does not cover
major surgery unless the medical opinions of two other licensed physicians or dentists concurring on the
necessity of such surgery are obtained prior to the performance of such surgery. This completed form may be
photocopied.
Signature of Parent or Guardian: _________________________________________________________
Printed Name _______________________________________ Date _____________________________
Part II, REFUSAL TO CONSENT
I do not give my consent for emergency medical treatment of my child. In the event of illness or injury
requiring emergency treatment, I wish the Nature Center authorities to take no action or
to: __________________________________________________________________________________
Signature of Parent/Guardian: ______________________________________ Date __________________

All sections must be completed for attendance
Photo Release For Marketing Purposes
I give permission to the Nature Center at Shaker Lakes to make commercial, non-commercial, social media, and
web content use of any activity photographs of my child during this program.
Signature of Parent/Guardian: _________________________________________ Date _________________
I do not give permission to the Nature Center to photograph my child. Signature: _________________________
Please take the time to answer all questions. Write N/A if a question does not apply. DO NOT LEAVE BLANK
Dietary Needs: □ Kosher □ Vegetarian
Does not eat: □ Meat □ Pork □ Dairy products □ Wheat □ Peanuts □ Eggs □ Other _____________________________
Allergies- Include medication, food and others (insect stings, hay fever, asthma, animal dander, etc.)
List all known. Describe reaction and management of the reaction.
_______________________________ ___________________________________________________________________
_______________________________ ___________________________________________________________________
_______________________________ ___________________________________________________________________
_______________________________ ___________________________________________________________________
Does your child carry an Epi E-Z Pen? _________________
If yes, please explain ____________________________________________________________________
Special needs: List any of which the staff should be aware (medical, emotional, learning, social)
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Explain any restrictions to activity (e.g., what cannot be done, what adaptations or limitations are necessary)
_____________________________________________________________________________________________________
Medications: Applies to medications that must be taken at lunch or for our overnight programs.
Please list ALL medications (including over-the-counter or non-prescription drugs) taken routinely. Bring enough
medication to last the entire week of camp. Keep medication in the original packaging/bottle that identifies the
prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of
administration.
My child takes NO medications on a routine basis. OR My child takes medications as follows:
Med #1___________________Dosage___________Specific times taken each day__________________________
Reason for taking_________________________________________________________________________________
Med #2___________________Dosage___________Specific times taken each day__________________________
Reason for taking_________________________________________________________________________________
Attach additional pages for more medications.
Identify any medications taken during the school year that participant does/may not take during the summer:
________________________________________________________________________________________________
________________________________________________________________________________________________
Insurance Information *FOR OVERNIGHT CAMPERS ONLY*
Is the participant covered by family medical/hospital insurance? Yes No
If so, indicate carrier or plan name_________________________________Group#__________________________________
Carrier address_________________________________________________________________________________________
Name of insured_______________________________________ Relationship to participant___________________________
Social Security number of policy holder or Insurance ID number__________________________________________________

Ohio Department of Job and Family Services
REQUEST FOR ADMINISTRATION OF MEDICATION
Child Care Centers and Type A Homes
This form is valid for no longer than twelve (12) months. One form must be used for each medication.
Box 1 - The following section must always be completed by the parent/guardian.
Check all that apply:
Prescription medication
Nonprescription medication
Refrigeration required
Topical product or lotion
Food supplement
Modified diet
Complete all of the following information:
Name of child: _____________________________________________ Date of birth: Weight
Name of medication: ________________________________________ Exact dosage: _______________________
To be administered at the following times: __________________________________________________________
For the following period of time: __________________________________________________________________
Parent/Guardian signature:
Date:
Box 2 -The following section must be completed by a licensed physician, a licensed dentist or an advance
practice nurse when:
1. A physician's instruction is needed for a nonprescription medication (e.g. child is underage or underweight
per the label instructions); or
2. It is a sample medication without a prescription label; or
3. The nonprescription medication is to be given longer than three consecutive days within a fourteen day period
or is a topical product or lotion that is being used for a skin ailment and is to be given no longer than fourteen
consecutive days; or
4. The child is on a modified diet (an entire food group is eliminated); or
5. The medication contains codeine or aspirin.
______________________________________ is under my care and should receive _________________________
(name of child)
(name of medication, vitamin, diet)
as follows: ____________________________________________________________________________________
(include dosage and instructions)
Possible side effects to watch for are: _______________________________________________________________
Expiration date: (may not exceed 12 months from the date of this request for medications or food
supplements)
______________________________________________ ____________________________________
Signature of physician, dentist or advance practice nurse Date of signature Phone number
Box 3 - The section below must be completed by the center or type A home staff and each administration of
medication must be documented. All dosages must be recorded on the reverse side of this form.
____________________________________ was given ______________ in the amount of __________________
(Name of Child) (Name of Medication, (Dosage)
Vitamin or Diet)
This form must be used by child care centers and type A homes to meet the requirement of rules 5101:2-12-31 and 51-1:2-13-31.
JFS 01217 (Rev. 9/2005) Page 1 of 2

Date and Time of Dosage Dosage Amount Signature of Designated Person Administering Medication
This form must be used by child care centers and type A homes to meet the requirement of rules 5101:2-12-31 and 51-1:2-13-31.
JFS 01217 (Rev. 9/2005) Page 2 of 2