HEALTH & EMERGENCY CARE

RELEASE FORM

Camper Information

Camper's Name(Required)
Address(Required)

Parent/Guardian Information

1st Parent/Guardian Name(Required)
Parent/Guardian's Email(Required)
Best way to contact during camp hours?(Required)
2nd Parent/Guardian Name
Best way to contact during camp hours?(Required)

Emergency Contacts

In case we cannot reach the Parent(s)/Guardian(s) listed above, please provide emergency contacts:
Emergency Contact #1 Name(Required)
Emergency Contact #2 Name(Required)

Pick-Up Authorization

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

Medical Information

Does your child have any medical conditions that would affect his/her participation in our program?(Required)
Will your child need to take any medications during camp hours?(Required)
If YES is your child able to self-administer all medication?
Does your child suffer from any of the following? If so, please provide dates and/or frequency below:
Does your child carry an epinephrine kit?(Required)
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?
Where will the kit be during camp?

Additional Needs

Does your child have any other 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.

Catamount Outdoor Family Center Release Statement

Please enter your full name here
I Consent(Required)
MM slash DD slash YYYY
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