Medical Release Form

For camp participation, a Medical Release Form is required for each participant. You can fill out and submit the medical form to education staff below or fill out this form, scan it, and email it to enixon@highlandscenter.org.

Thank you for enrolling your child in our program. In order to meet our standards of safety we require a completed medical form for each child. Please fill out each section carefully, including the back page. If your child has participated in a camp this year (2021), we do not need a new medical form. We look forward to having a wonderful and safe outdoor experience with your child!
Today's Date*
MM
DD
YYYY
Start Date of Camp Attending*
MM
DD
YYYY
Child's Name*
First Last
Age*
Date of Birth*
Gender*
Parent/Guardian Name*
First Last
Relationship to child*
Email*
Enter Email Confirm Email
Address*
Address City State ZIP Code
Daytime Phone*
Cell Phone*
Parent/Guardian Name
First Last
Relationship to child
Email
Enter Email Confirm Email
Address
Address City State ZIP Code
Daytime Phone
Cell Phone
Emergency Contact(s) – Please provide in order of who should be contacted – for example if the camper is staying with someone other than the parent they should be listed as the primary contact:
Emergency Contact*
First Last
Relationship to child*
Phone Number*
Other Phone Number
Emergency Contact
First Last
Relationship to child
Phone Number
Other Phone Number
The following person(s) may be dropping off or picking up my child from the center:
Please list their name, relationship, and phone number.
The following person(s) may NOT remove my child from the center:
Please list their name.
Consent*
I herby give permission for my child to participate in all Highlands Center program activities. I understand that my child will be outside for most of the day exploring the forest, creek and other ecosystems of the Highlands Center and that participation in these activities involves inherent risks of physical injury or loss of personal property.
I herby give permission
Signature*
Today's Date*
MM
DD
YYYY
Medical information
Is your child allergic to certain foods or other substances? If so, name foods or substances to be avoided and procedure to follow if reaction occurs.*
Is your child subject to fainting, seizures, or convulsions, and what should be our procedure if one occurs?*
Does your child have any physical condition that we should be aware of (heart trouble, foot problems, hearing impairment, hernia, etc.)? If so, what precautions need to be taken?*
Is your child taking any medication? If so, will the medication need to be administered during our program?*
Basic medical care is administered for minor scratches and/or bites and stings. Over the counter (OTC) brands that we may use include but are not limited to: Band-Aid, Neosporin ointment, Equate Triple Antibiotic ointment, topical Benydril, Anti-Itch cream, After Bite cream, Calamine lotion, and Hall’s cough drops. Please list any specific OTC medications that you do NOT want administered to your child.*
Please note: Students may NOT carry any kind of medication. It must be kept with a Highlands Center staff person and administered according to a doctor’s or parent’s instructions. All medication must be in the original container and show instructions. In the case of prescription medications, the doctor name and student name must also show. A parent or guardian must hand deliver the medication to a Highlands Center staff person at the start of the program.
Additional comments or other special instructions:*
If medical care is necessary, call:
Doctor
First Last
Address
Address City State ZIP Code
Phone Number
Hospital
Address
Address City State ZIP Code
Phone Number
Call first in case of injury or sudden illness:
I hereby give authority to any hospital or doctor to render immediate aid as required at the time for the child’s health and safety. I understand that I am responsible for all expenses of these services.
Parent/guardian Name
First Last
Today's Date*
MM
DD
YYYY
The enrollment and emergency information on this form was provided by:*
First Last

Summer Camps

Learn more about our Summer Camps at the Highlands Center.

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Medical Release Form

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