Catamount Outdoor Family Center Youth Health Release Form

Camper Information

Camper's Name*

First Last

Entering Grade*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Information

1st Parent/Guardian Name*

First Last

Home Phone*

Cell Phone*

Work Phone*

Parent/Guardian's Email*

Enter Email Confirm Email

Best way to contact during camp hours?*

Home Phone
Cell Phone
Work Phone
Text to Cell Phone

2nd Parent/Guardian Name

First Last

Home Phone

Cell Phone

Work Phone

Best way to contact during camp hours?*

Home Phone
Cell Phone
Work Phone
Text to Cell Phone

Emergency Contacts

In case we cannot reach the Parent(s)/Guardian(s) listed above, please provide emergency contacts:

Emergency Contact #1 Name*

First Last

Emergency Contact #1 Phone*

Relation

Emergency Contact #2 Name*

First Last

Emergency Contact #2 Phone*

Relation

Pick-Up Authorization

Please list all adults (including parents) authorized to pick up your child:

1.*

2.

3.

4.

Medical Information

Does your child have any medical conditions that would affect his/her participation in our program?*

Yes
No

If YES please explain.

Will your child need to take any medications during camp hours?*

Yes
No

If YES, please indicate type of medications and the purpose:

If YES is your child able to self-administer all medication?

Yes
No

Does your child suffer from any of the following? If so, please provide dates and/or frequency below:

Ear Infections
Frequent Colds
Hay Fever
Penicillin Allergy
Reaction to Poison Ivy
Reaction to Insect Stings
Bleeding Disorder
Food/Other Allergies

Comments/Dates/Frequency

Does your child carry an epinephrine kit?*

Yes
No

Due to the public nature of our site, we cannot guarantee that the area is peanut/nut free.

Does s/he know how to use it?

Yes
No

Where will the kit be during camp?

Yes
No

Special Needs

Does your child have any special behavioral or physical needs? Please share information about your child’s mental, emotional and physical health that will enable us to better serve him/her, and describe strategies you’ve found effective in addressing this need.

Details

Catamount Outdoor Family Center Release Statement

As a parent of*

I Consent*

By checking this box you consent to this Release Statement

* I understand that Catamount Outdoor Family Center will keep this information confidential and will review the information solely to assess if requested accommodations are reasonable and do not fundamentally alter the services provided.

* In this event that Catamount Outdoor Family Center is unable to reach a parent/guardian or emergency contact by phone while my child is at Catamount Outdoor Family Center, I hereby authorize Catamount Outdoor Family Center staff or medical personnel to take emergency measures as needed.

* I realize fully that even after reasonable precautions are taken some activities such as but not limited to biking, hiking and trail running may involve inherent risks for which Catamount Outdoor Family Center and it’s partners and affiliates cannot be held responsible.

* I understand that no part of the camp program fee is to be refunded in the event of dismissal or withdrawal due to illness, injury or unexpected family obligations.

* I grant Catamount Outdoor Family Center permission to use photographs of my child in program related activities for promotional materials, including but not limited to brochures, flyers, newspaper advertisements, Catamount Outdoor Family Center’s website, Facebook page and Instagram account.

Today's Date*

Email

This field is for validation purposes and should be left unchanged.

HEALTH & EMERGENCY CARE

RELEASE FORM

Camper Information

Parent/Guardian Information

Emergency Contacts

Pick-Up Authorization

Medical Information

Special Needs

Catamount Outdoor Family Center Release Statement