Health and Consent Form - Living History Farms, Iowa

- Children registered for day camp must have a health form completed by a parent or guardian regarding allergies, chronic illnesses or medications.
- One Health & Consent Form for each child participating in day camp must be completed, and submitted to Living History Farms no later than two weeks after registering, or we will be unable to process your registration.
- A physical is not required to attend day camp.

Camper Name*

First Last

Camp Name*

Which camp are you attending?

Parent or Guardian's Email*

Please enter a valid email address where we may contact you if we have any questions.

Male or Female Camper?*

Emergency Contact*

(other than parent/s, within a 30 minute drive)

First Last

What is the emergency contact's relationship to the camper?*

Emergency Contact's Phone*

Emergency Contact's Cell Phone

If different from number above.

Physician's Name*

Preferred Hospital*

Please note any allergies or physical conditions of which we need to be aware.

Current medications

Please bring a daily dosage of medication. Counselors are not authorized to dispense or to monitor the taking of medications, but will remind campers to take them.

Date of camper's last tetanus shot?*

This question is required by the American Camp Association as part of Living History Farms' accreditation.

Are the camper's immunizations up-to-date?

This question is included as part of Living History Farms' accreditation by the American Camp Association.

Record of past medical treatment

This question is included as part of Living History Farms' accreditation by the American Camp Association.

Are there any activities from which your camper should be exempted from for health reasons?

This question is included as part of Living History Farms' accreditation by the American Camp Association.

Camper's Insurance Carrier and Policy Number*

This question is required by the American Camp Association as part of Living History Farms' accreditation.

Authorization for Treatment

I hereby give my permission to the medical personnel selected by the Day Camp Coordinator to order x-rays, routine tests, treatments, and necessary transportation for the child named above. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Day Camp Coordinator to secure and administer treatment, including hospitalization, for the child named above.

Signature of Parent/Guardian*

Signature typed here constitutes a legal and binding signature.

Date*

Living History Farms Day Camp program is accredited by the American Camp Association, the only nationwide organization that accredits all types of organized camps.

Name

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

Day Camp Health & Consent Form

Authorization for Treatment