Medical Form | Calypso Farm

Medical Information & Media Release

Below is the medical information and media release required for participation in Calypso's youth programs.

Please contact us if you have any questions or concerns: 907-451-0691 or leila@calypsofarm.org

"*" indicates required fields

Child's Information

Name of Child*

First Last

Age*

My child is participating in:*

Summer Camp

Youth Leadership Program

Farm School

Allergies & Medications

Does your child have any known allergies?*

Yes

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

If yes, 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.

Over the Counter Medications*

Calypso First Aid kits are equipped with over-the-counter Diphenhydramine (Benadryl) that can be administered in the case of allergic reactions (when other interventions are not indicated). Do Calypso Farm staff members have your permission to administer Diphenhydramine (Benadryl) as needed?

Yes

Health History

Does your child have any activity restrictions?*

Yes

If yes, please describe them here:

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

A recent injury, illness, or infectious disease

A chronic or recurring illness or condition

Diabetes or problems with blood sugar control

Seizures

Fainting or dizziness

Asthma or wheezing

Skin problems

Ever been stung by a bee?

None of the above

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

Dietary Restrictions:

We do a lot of cooking from the garden during Farm programs. In addition to any allergies listed above, does your child have any dietary restrictions we should be aware of? If so, describe below.

Other Needs:

Does your child have any social, developmental, or behavioral needs that we should be aware of? If yes, please describe below, and how we can support them:

COVID-19

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

Physician Information

Name of Primary Care Physician*

Phone Number:*

Emergency Contacts

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

Relationship to child:*

Cell phone number:*

Best daytime phone:*

Best evening phone:*

Address*

Street Address City State ZIP Code

Name of additional emergency contact:*

Relationship to child:*

Cell phone number:*

Best daytime phone:*

Best evening phone:*

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*

I hereby grant Calypso Farm & Ecology Center staff and/or volunteers permission to take photographs or video of the child listed above, as well as the right to edit, use and reuse said products for non-profit and promotional purposes, including use in print and digital 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.

Yes, I consent

No, I do not consent

Other

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*

Month

Day

Year

Medical Information & Media Release

Child's Information

Allergies & Medications

Health History

Physician Information

Emergency Contacts

Media Release & Signature

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