What Happens at JAZZ CAMP
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Camp Heebie Jeebies
Health Form
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Bring this completed form to Camp
Camp Heebie Jeebies
Health and Liability Release Form
Student _______________________________ Date of Birth _______ Phone_________________
Address ____________________________________________ Female ______ Male ________
City , State, Zip__________________________________ Email___________________________
Is this participant in general good health and able to participate in all normal Camp Heebie Jeebies activities?
Yes_________ No_________ (If NOT, please submit a statement indicating limitations)
Name of Family Physician __________________________________________________________
Address/Phone____________________________________________________________________
PARENT/GUARDIAN: Please read carefully and complete this section:
While participating in activities at Camp Heebie Jeebies, each student is assumed to be voluntarily performing activities for which he/she assumes all risk, consequences, and potential liability. By signing this form, I hereby release Camp Heebie Jeebies and Camp David Jr. and their agents from any and all claims by reason of accident, injury, illness, death, or any other consequences arising or resulting directly or indirectly from participation in activities at Camp Heebie Jeebies held at Camp David Jr., Lake Crescent, WA.
In case of a medical emergency, I understand that every effort will be made to contact parent(s) or guardian of participants. In the event that I cannot be reached, I hereby give permission to the physician selected by the Camp Nurse and/or the director of Camp Heebie Jeebies to hospitalize, secure proper treatment, for and to order injection, anesthesia or surgery for my son/daughter as named herein. I also give permission for the release of medical records to an attending physician in case of illness or accident.
The procedure we follow for medical emergencies is to give first aid immediately and then transport the person to the Port Angeles medical center. If an ambulance is required, staff members will call 911, and the injured person will be driven toward Port Angeles to meet the ambulance midway (the distance is 30 miles from the camp to Port Angeles).
SIGNATURE OF PARENT/GUARDIAN __________________________________________
PHONE _______________________________ E-Mail address ______________________
HEALTH INSURANCE CO. ___________________________ POLICY # _______________
DATE _____________________
Please fill out the questions on the next page.
IMMUNIZATION HISTORY:
(All immunizations are the responsibility of the student in consultation with family physician or clinic)
Please give dates:
DPT _______________ DPT Booster ____________ Tetanus Booster__________
Polio Series _____________________________________ Polio Booster ____________
MMR __________________________________________ MMR Booster ___________
ALLERGIES/CHRONIC CONDITIONS:
(Please write YES or NO next to each)
Hay Fever ______________ Sulfa ______________ Fainting ________________
Convulsions ____________ Asthma ____________ Poison Ivy ______________
Bee Sting ______________ Other __________________________________________
If you answer YES to any of the above, please submit a statement detailing how the student has been treated and which medications have been used.
OPERATIONS OR SERIOUS INJURY: (Please include dates)_________
COMMUNICABLE DISEASE: Please notify Camp Director if this student has been exposed to any communicable disease during the three weeks prior to attendance at Camp Heebie Jeebies.
DIETARY REQUIREMENTS: Please write below any dietary requirements that are essential for the student’s well-being. We are not able to provide a complete “vegan” diet; however, there are salads, fruit, fresh-cut vegetables, and peanut butter/jelly sandwiches available at every meal. If there is a particular food item that the student must have each day, it would be wise to bring it along. We have refrigeration and freezer space available.
Revised 7-11-10