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.

"*" indicates required fields

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, 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*

Start Date of Camp Attending*

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

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.

Signature*

Today's Date*

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.*

Has your child been diagnosed with, or being treated for a physical, emotional, or cognitive condition? (ADD/ADHD, hearing impairment, autism, hernia, etc.) If so, please explain:*

Is your child taking any medication? If so, will the medication need to be administered during our program?*

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.

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.*

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*

The enrollment and emergency information on this form was provided by:*

First Last

Photo Release and Social Media Release

I hereby grant to the Highlands Center for Natural History, their legal representatives and assigns, permission to copyright, duplicate, edit, distribute, and/or otherwise use photographic images, and /or audio images of me, or images in which I am included, in whole or in part, for advertising including social media (Facebook, Twitter, and Instagram), or any lawful purpose, whatsoever.

I hereby waive any right that I may have to inspect or approve the finished product or products, or the advertising, or other visual or audio matter that may be used or developed in connection with the above defined images, or the use to which they may be applied.

I hereby warrant that I have every right to contract for myself in my own name in the State of Arizona in the above regard, and, if applicable, I am the legal Parent or Guardian of the above named minor child/children.

Photo Release and Social Media Release*

I hereby warrant all of the above

I do not warrant all of the above (do not take photos of above minors)

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