2019 Counselor-In-Training Health Form & Photo Release - Nature Day Camp
Counselor-in-Training Health Form
The following medical and health information may help in the unlikely event of an accident or sudden illness. Please complete this form as accurately as possible. Inaccurate or incomplete information can limit medical personnel’s ability to treat your child. Please read it through carefully, before filling it out. We respect your child's privacy and will only share the information with Chippewa Nature Center staff and necessary emergency or medical personnel.

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My child is sufficiently fit to participate in this Chippewa Nature Center program. I have completed this form with health disclosure information that is accurate, complete, and true to the best of my knowledge. I agree to notify the Program Leader(s) of any changes to my child's health and fitness that may occur before or during the program. Should my child become ill or injured, I give permission for the Program Leader(s) to render first-aid and to seek emergency medical or rescue services, as they see fit and at my cost. I also hereby give permission for my child to receive emergency medical attention from a physician in the event of illness or injury.
*CIT's First Name:
*CIT's Last Name:
What name would your child like to be called?
Example: Nathan (instead of Nathaniel) If helpful, please provide a phonetic spelling. Example: Elise = EE-lees
*Birthdate:
*Gender
*Height
*Weight
*Does your child wear corrective eyeglasses or contact lenses?

Allergies
*What allergies does your child have (food, plants, etc)?
Please tell us about any allergies your child has. If there are none, state "None."
*Does your child carry an epi pen?
If your child carries an epi pen, which allergy is it for?

Other Health Information
Does your child have any of the following conditions?








*Is your child currently taking any medications?
*Has your child had their appendix removed?
Has your child had any other surgeries?
*What was the date of participant's last tetanus shot?
*Is your child up to date on his/her other vaccinations?

Additional Information
If no questions are displayed, no additional information is needed.
Other Information
*Please explain any limitation or needs CNC staff should be aware of in providing the best experience for your child.
*Does your child have any fears we should be aware of? (e.g. heights, dark, dogs, insects, water)
If applicable, please list any other concerns or information you would like to share with Chippewa Nature Center staff:
Emergency Contact Information
If you would like parents to be the first people contacted in an emergency situation, please provide that contact information in the first section. In an emergency, we will go through these contacts in order, leaving messages at each number until we reach someone or receive a call back.
*Name
*Relationship
*Phone number (please specify Home, Cell, or Work)
Alternate phone number (please specify Home, Cell, or Work)

*Name
*Relationship
*Phone number (please specify Home, Cell, or Work)
Alternate phone number (please specify Home, Cell, or Work)

*Name
*Relationship
*Phone number (please specify Home, Cell, or Work)
Alternate phone number (please specify Home, Cell, or Work)
Counselor-in-Training Release
*I authorize all of the people listed in the Emergency Contact Information section to pick up my child from programs at Chippewa Nature Center.
*Please provide the name and relationship for any other individuals you allow to pick up your child from programs at Chippewa Nature Center. (e.g., Jane Doe, aunt)

Model/Photo Release
*I authorize the use and reproduction of any and all photographs or videos that have been or will be taken of my child by CNC. I give the absolute right and permission to copyright, publish, display, and use these photographs for programming, marketing, or promotion. I undestand that CNC will not publish my child’s name with any photo. I have read and understand this paragraph and am fully aware of its contents and implications.
Authorization to Dispense Medication during Camp
I authorize the following medications to be administered to my child according to labeled instructions by a member of the Nature Day Camp Staff. (Mainly for use during Trips & Overnight Camps)
 








Is there any additional information you'd like share regarding the administration of medications?