Outdoor Adventure Camp Emergency Medical Authorization And ...

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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
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