Medical Form | Calypso Farm

Camper Information

Name of Child*

First Last

Age*

My child is participating in:*

Farm School: Thursday Session
Farm School: Friday Session
Farm School: Saturday Session

Does your child have any activity restrictions?*

Yes
No

If yes, please list them here:

Medications & Allergies

Over-the-Counter Medications

Calypso Farm staff members have my permission to administer the following over-the-counter medications as needed:

Does your child have any known allergies?*

Yes
No

If yes, please list known allergens, allergic reaction seen, and how to manage the reaction (including use of medications):

Will your child be carrying and self-administering any medication?

If yes, you are acknowledging that it is your child's responsibility to know proper dosage and time of administration.

Yes
No

List medication:

Self-Administration of Medication for Asthma and Anaphylaxis (Inhalers or Autoinjectable Epinephrine)

By checking this box, I am agreeing to the following statement:

As the parent/guardian of the child, I do hereby request that Calypso Farm & Ecology Center staff permit my child to carry and self-administer medication approved by the child's health care provider. I agree not to institute suit against Calypso Farm & Ecology Center for administration or non-administration of the medication, to defend and hold Calypso Farm & Ecology Center harmless from any liability resulting from the administration or non-administration of the medication and to defend and indemnify Calypso Farm & Ecology Center and its employees from any liability arising out of this agreement.

I will notify Calypso staff immediately if the medication is changed. I acknowledge that if the child self-administers epinephrine, the child must notify Calypso staff prior to administration and that 9-1-1 (Emergency Medical Services) must be called.

Physician & Health Insurance

Name of Primary Care Physician

Phone

Health Insurance Provider

Policy Number

Health History

Does your child have a history of or are they currently experiencing any of the following?

A recent injury, illness, or infectious disease?*

Yes
No

A chronic or recurring illness or condition?*

Yes
No

Diabetes or problems with blood sugar control?*

Yes
No

Seizures?*

Yes
No

Fainting or dizziness?*

Yes
No

Asthma or wheezing?*

Yes
No

Skin problems (rashes, etc.)?*

Yes
No

Ever been stung by a bee?*

Yes
No

If you answered "YES" to any of the questions above, please describe any health concerns we should be aware of and, if emergency medical action may be necessary, please describe the appropriate intervention.

COVID-19

During our 2021 season, Calypso will be practicing COVID-19 mitigation measures in all our educational programs, including Farm Camp. This includes limiting program group size, using mostly outdoor spaces, practicing social distancing, encouraging frequent hand washing or sanitizing, and eliminating the mixing of multiple on-site programs. All participants ages 5 and up who can safely wear a mask per CDC guidance will also be required to wear a face mask during our programs.

Is there anything additional we should be aware of when it comes to your child’s health in the context of COVID-19? Please describe below.

Emergency Contacts

Name of Emergency Contact #1 (Parent/Guardian):*

Relationship to child:*

Daytime phone number:*

Evening phone number:*

Cell phone number:*

Address*

Street Address Address Line 2 City State ZIP Code

Name of additional emergency contact:*

Relationship to child:*

Daytime phone number:*

Evening phone number:*

Cell phone number:*

Please list any approved individuals allowed to transport your child to and from camp:

Transportation Consent*

By checking this box, I am agreeing to the following statement:

I agree for myself and on behalf of my child to waive all liability, and to release and hold harmless Calypso Farm & Ecology Center, its staff members and volunteers in the event of injury, death or damage to person or property that occurs as a result of my child's transportation to or from Camp. I agree for myself and on behalf of my child not to assert against Calypso Farm & Ecology Center, its board members, staff and volunteers, in any court of law, any claims whether known or unknown, that arise as a result of such transportation.

Media Release & Signature

Media Release for a Minor

By checking this box, I am agreeing to the following statement:

I hereby grant Calypso Farm & Ecology Center staff members and/or volunteers permission to take photographs or video of the child listed above. I also grant Calypso Farm & Ecology Center the right to edit, use and reuse said products for nonprofit purposes, including use in print, digital, and all other forms of media. I hereby release Calypso Farm & Ecology Center and its agents, staff and/or volunteers from all claims, demands and liabilities in connection with the use of video or photographs.

Electronic Signature*

By checking this box I am agreeing to the following statements and electronically signing this document:

I, the parent/guardian of aforementioned child:

1. Verify that all information on this form is complete and accurate.

2. Give permission for Calypso Farm & Ecology Center Staff to administer appropriate medical care if needed.

3. Waive Calypso Farm & Ecology Center of all liability for any accident, injury, or illness that occurs.

4. In the case of an emergency, permit Calypso Farm & Ecology Center staff to share my child’s medical information.

Name of parent/guardian:*

Date*

Medical Information & Media Release

Camper Information

Medications & Allergies

Physician & Health Insurance

Health History

Emergency Contacts

Media Release & Signature

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