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2024 Teen Volunteer Health Form & Photo Release - Nature Day Camp
Teen Volunteer Health Form - Nature Day Camp
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.
*
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.
Yes
No
This item is required
*
Teen Volunteer's First Name:
Teen Volunteer's First Name: is required
*
Teen Volunteer's Last Name:
Teen Volunteer's Last Name: is required
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:
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2006
2007
2008
2009
2010
2011
2012
Month of Birthdate: is Required
Day of Birthdate: is Required
Year of Birthdate: is Required
Birthdate: must be on or after 6/5/2006 and on or before 8/8/2012
*
Gender:
Gender: is required
*
Height
Height is required
*
Weight
Weight is required
*
Does your child wear corrective eyeglasses or contact lenses?
Yes
No
Does your child wear corrective eyeglasses or contact lenses? is required
Allergies
*
What allergies does your child have (food, plants, etc)?
If there are none, state "None."
What allergies does your child have (food, plants, etc)? is required
*
Does your child carry an epi pen?
Yes
No
Does your child carry an epi pen? is required
If your child carries an epi pen, which allergy is it for?
Other Health Information
Does your child have any of the following conditions?
Asthma
Hypertension
Epilepsy/Seizures
Blackouts/Dizziness
Rheumatic Fever
Diabetes
Heart Disease
None
Other:
Other: cannot be blank
*
Is your child currently taking any medications?
Yes
No
Is your child currently taking any medications? is required
*
Has your child had their appendix removed?
Yes
No
Has your child had their appendix removed? is required
Has your child had any other surgeries?
Yes
No
*
What was the date of your child's last tetanus shot?
What was the date of your child's last tetanus shot? is required
*
Is your child up to date on their other vaccinations?
Yes
No
Other:
Is your child up to date on their other vaccinations? is required
Other: cannot be blank
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.
Please explain any limitation or needs CNC staff should be aware of in prov... is required
*
Does your child have any fears we should be aware of? (e.g. heights, dark, dogs, insects, water)
Does your child have any fears we should be aware of? (e.g. heights, dark, ... is required
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
Name is required
*
Relationship
Relationship is required
*
Phone number (please specify Home, Cell, or Work)
Phone number (please specify Home, Cell, or Work) is required
Alternate phone number (please specify Home, Cell, or Work)
*
Name
Name is required
*
Relationship
Relationship is required
*
Phone number (please specify Home, Cell, or Work)
Phone number (please specify Home, Cell, or Work) is required
Alternate phone number (please specify Home, Cell, or Work)
*
Name
Name is required
*
Relationship
Relationship is required
*
Phone number (please specify Home, Cell, or Work)
Phone number (please specify Home, Cell, or Work) is required
Alternate phone number (please specify Home, Cell, or Work)
Teen Volunteer 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.
Yes
No
I authorize all of the people listed in the Emergency Contact Information s... is required
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.
Yes
No
I authorize the use and reproduction of any and all photographs or videos t... is required
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)
Acetaminaphen (e.g., Tylenol)
Bismuth subsalicylate (e.g., Pepto Bismol)
Diphenhydramine (e.g., Benadryl)
Hydrocortisone cream
Ibuprofen (e.g., Advil, Motrin)
Calcium carbonate (e.g., Tums)
Topical antibiotic cream
Dimenhydrinate (Dramamine)
Do NOT administer any medications
Is there any additional information you'd like share regarding the administration of medications?
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