Participant Info, Health, & Consent Form

Registration for day camp is not considered complete until we receive this form.
One form for each child participating in day camp must be completed, and submitted to Living History Farms within 5 business days of paying for camp. Failure to fill out and return the form will result in your payment being canceled.
Children registered for day camp must have a health form completed by a parent or guardian regarding allergies, chronic illnesses or medications.

Camper and Parent Information
Camper's Name*
First Last
Camper's Birthday*
MM
DD
YYYY
Camper's Grade in the Fall*
Camper's Gender?*
Which camp are you attending?*
Which camp are you attending?*
Select which Winter Break Camp your child is attending.
Today
Date Format: MM slash DD slash YYYY
Camp Name*
Which camp are you attending?
Parent/Guardian 1 Name*
First Last
Parent/Guardian 1 Phone*
Parent/Guardian 2 Name*
First Last
Parent/Guardian 2 Phone*
Primary Contact Email*
Please enter a valid email address where all camp-related emails will be sent.
Notes
Please tell us any other information we need to know to make camp successful for your child.
Who is authorized to pick up your child?*
They must present a photo ID at pick up.
Policies
Photography Policy*
By participating in Living History Farms camp, I acknowledge that the museum has permission to use photography/video of my child(ren) in promotional materials.
I agree to the photography policy.
COVID-19 Policy and Procedures*
By sending your child to summer day camp, you agree to abide by all of the museum’s policies and procedures regarding COVID-19.
• Campers are required to wear masks or face coverings. Exceptions will be made for those with medical conditions. Campers will not be permitted to attend camp if they refuse to wear a mask.
• Daily temperature checks upon arrival. Campers with a temperature of 100.4 degrees F or higher will not be permitted to attend camp.
• You will receive a Health Screening Form in your pre-camp information email. This form must be turned in at the start of camp. If you answer “yes” to two or more questions, your camper will not be permitted to attend camp. You must fill out a screening form for each child attending camp.
• Camps will have small group sizes. Groups will be distanced from one another as much as possible.
• We have enhanced the cleaning and disinfecting at each camp site.
• There will be frequent handwashing with soap and water, or use of hand sanitizer when soap and water are not readily available.
• We have modified activities and crafts, to minimize sharing supplies.
• Museum and camp staff and volunteers will wear face masks and complete daily health screenings.
• If your camper is feeling sick in the morning, please refrain from sending them to camp. If they develop symptoms during the day while at camp, they will be isolated and you will be notified.
• Any changes to the policies and procedures will be communicated to you as needed. You may also check our website for the most up-to-date information.
I understand and agree to abide by the policies and procedures regarding COVID-19.
Camp Activities*
I give permission for my child to participate in the activities related to this camp.
Yes, my child has permission to participate in camp activities.
Emergency Contact and Health Information
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*
Date Format: MM slash DD slash YYYY
Living History Farms Day Camp program is accredited by the American Camp Association, the only nationwide organization that accredits all types of organized camps.
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Phone
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Participant Info, Health, & Consent Form

Camper and Parent Information

Policies

Emergency Contact and Health Information

Authorization for Treatment