For-Mar Nature Day Camp
Health History & Release Form

(Please fill out ONE form per camper) The information in this form does not affect the camper acceptance process.

For-Mar Nature Day Camp Health History & Release Form
Camper Name(Required)
Camper Group
Allergies(Required)
Allergies
Allergy
Reaction
 
Toileting(Required)
All campers must be able to use the toilet independently prior to starting camp. Using the toilet independently is defined as the camper asks to go to the bathroom when needed. In addition, being able to wipe themselves, pull up their pants, flush, and wash their hands.
Diet/Nutrition(Required)
Special Dietary Needs
Doctor/Health Insurance(Required)
This camper is covered by family health insurance
Immunizations(Required)
My child is up to date on immunizations:
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission for For-Mar Nature Day Camp to provide care to my child based on their Health Service Policy. I give permission to For-Mar Nature Day Camp to secure proper emergency medical treatment, surgical treatment, and routine non-surgical medical care, related to the health of my child. I understand the information on this form will be shared on a “need-to-know” basis with camp staff. I give permission to photocopy this form.
General Health History(Required)
Has/does the camper: (Check if Yes and explain below)
Mental, Emotional, and Social Health(Required)
Has/does the camper: (Check if Yes and explain below) Note: This information is confidential, and is only to ensure adequate accommodations are made for each camper. This information does not affect the camper acceptance process
Medication(s), Inhaler, Epi-pen, etc.(Required)
  • If Yes, you MUST fill out a “Weekly Medication Log” form.
  • If the camper needs to take any medication(s), inhaler, and/or epi-pen during camp hours, when you check your camper in, bring enough medication to last the full week of camp.
  • ALL MEDICATIONS MUST BE SUBMITTED IN THEIR ORIGINAL CONTAINER, and be clearly labeled with instructions including the prescribed patient name, prescribing physician, the name of the medication, the dosage, and the frequency of administration.
  • If your child uses an inhaler and/or an epi-pen, they MUST bring a doctor’s note to carry it on them.
  • It is your responsibility to update us on the status of your child’s medical conditions if there are changes at any time throughout camp.
Medications
Please list ALL medication(s)/inhaler/epi-pen, etc. to be taken during camp hours, and/or any non-routine medications (Aspirin, Cough Drop, Cortisone, TUMS, etc.) to be taken on an as-needed basis:
Sunscreen/Bug Spray/Tecnu Policy(Required)
Check if you give permission for For-Mar Nature Day Camp Staff to use our standard supply of these items on your child. (If not checked camper may bring their own)
  • Any items brought from home MUST be labeled with Camper’s name
  • We understand that ticks are a concern. Parents/Guardians are responsible for doing a full tick check of their camper(s) at the end of each day.
Please use the space below to provide us with any information that will help your camper be successful while they’re at camp. This can include information pertaining to their social behavior, physical needs, medical or emotional habits. Any information that may affect their participation in camp programs and potential accommodations are useful.

CONSENT, RELEASE, and INDEMNIFICATION WAIVER

In consideration of my participation in the event, for myself, my heirs and assigns, and my representative, hereby assume all risk of personal injury or death and property damage, or loss from whatever causes arising, while I am on the premises owned by Genesee County, and release Genesee County, Genesee County Park and Recreation Commission and their officers, agents and employees from any liability therefore, directly and indirectly, and will defend, indemnify, and hold harmless the County, Parks and Recreation Commission, and their officers, agents, and employees from any such liability, whether or not arising out of neglect or will actions, or the failure to act on the part of the County, Parks and Recreation Commission or their officers, agents, and employees. The consideration for my agreement herein is my being allowed to engage in the activity referenced. The undersigned, on my behalf of myself and the people listed below, do hereby consent to the use by the Commission of our name, photograph(s), likeness, and voice for the use and re-use in conjunction with broadcasting, publicizing, and advertising for the Commission. I further grant the the Commission the right to license others to use and reuse the above cited material in the same manner.
Consent(Required)
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