Date of Birth (MM/DD/YYYY) *
Relationship to child *
Cell # (XXX)XXX-XXXX *
Relationship to child *
Cell # (XXX)XXX-XXXX *
Relationship to Child *
Cell # (XXX)XXX-XXXX *
Please describe the allergy, whether the allergy is caused by ingestion, touch or airborne and what the level of allergy is (mild, severe or anaphylactic)
If so, what kind?
If any are checked above, please explain in more detail here
Activity Restrictions: Does the camper have any restrictions to participating in activities, be it physical, mental or behavioral? If so, please describe restriction or adaptation needed.
Insurance Company
Policy Number
Subscriber
Insurance Company Phone Number
MEDICATIONS– Please list any medications the participant is currently taking, dosage, and reason for taking:
What else should we know? Please provide any additional information that would be helpful for staff to know for your child to have a safe and successful week.
Parent/ Guardian Authorization for Health Care: The Participant’s medical conditions and information stated on this application is complete and correct. I give permission to the Sow Joyful staff to (1) provide appropriate first aid for minor injuries; and (2) seek further treatment from local physicians or hospitals if the medical condition warrants. In the event I cannot be reached in an emergency, I also give permission to the treating physician to examine, diagnose, and treat or secure proper treatment for the Participant and hospitalize, and to order injection and/or anesthesia and/or surgery for the Participant, as the physician shall determine proper and necessary under the circumstances. I agree to assume f ull financial responsibility for the costs of any evacuation and/or medical treatment that the Participant may receive. A photocopy of this consent shall be as valid and may be accepted as the original. Typing my name below acts as my signature on this document. *
Relationship to participant *
I certify that I have completed all sections of this Health Form and accept full responsibility for any errors or omissions. The Participant has permission to take part in all program activities except as noted above. I understand the information on this form will be shared on a “need to know” basis with Sow Joyful staff. I fully understand that the Participant is to abide by all rules governing personal conduct during all activities. Any violation of these rules may result in the Participant being sent home at the expense of his/her parent/guardian. I understand that no refunds will be given for Participants sent home due to disciplinary procedures or illness and that it is my responsibility to pick up a Participant sent home for such a reason. Typing my name below acts as my signature on this document. *
Relationship to participant *