Health Form (Required)

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In order for any participant to attend Frenchman Bay Camp 2019, Frenchman Bay Conservancy and Maine Outdoor School must have a completed health form on file. Hazel Stark, Co-Founder of Maine Outdoor School and Leader of this program, is Wilderness First Responder certified and will carry a thorough first aid kit throughout the camp. Responses will remain confidential and only used to provide appropriate care to participants.

Please direct any questions to Hazel at Maine Outdoor School (hazel@maineoutdoorschool.org or 207.358.0412)

Email *

Dates your camper will attend *

July 16-18

August 5-7

Participant First and Last Name: *

Participant Date of Birth: *

YYYY

Participant's Address: *

Participant Age: *

Participant Gender: *

Female

Male

Prefer not to say

Other:

Name of Participant's Parent/Guardian: *

Parent/Guardian Phone Number: *

Parent/Guardian Best Method of Contact during Camp Dates: *

Emergency Contacts: people who, in an emergency, can find you or accept responsibility for your child if s/he needs to be picked up. List full names, phone numbers, and relationship to participant: *

Does the participant have any health concerns that might affect his/her care, such as asthma, diabetes, convulsive seizures, hearing or vision loss, etc.? Describe: *

Does the participant have any behavioral or learning diagnoses? Describe: *

Does the participant take any medications that will have to be administered during this program? If YES, you MUST make arrangements to address this need with Hazel at Maine Outdoor School (207.358.0412, hazel@maineoutdoorschool.org): *

Does the participant have any serious allergies to foods, insect stings, medications, or other substances? If YES, what is s/he allergic to? *

Is this allergy life threatening?

Yes

Other:

Clear selection

Is the allergy from:

Contact/touch

Ingestion/eating

Airborne/inhalation

Other:

Does the participant carry an Epi-Pen? *

Yes

Are there foods the participant CANNOT eat? *

Are there any limits to the participant’s physical activity (e.g. broken limbs, adapted PE, etc.)? If YES, please describe: *

Is the participant covered by health insurance? If YES, please list carrier and policy number: *

Name of Participant's Doctor: *

Participant's Doctor's Phone Number: *

We need to know if your child is protected against tetanus. Has your child had a recent diphtheria, pertussis, tetanus (Tdap) immunization or diphtheria, tetanus (Td) immunization? *

Yes

If YES, when was the last booster given?

YYYY

Parents/Guardians will be notified of any illness or injury to their child and appropriate care will be given. In the event of an emergency in which I cannot immediately be reached, I authorize medical and/or surgical care for my child while he/she is attending or en route to or from the Maine Outdoor School program. Select "YES" if you have read and understood this form: *

Yes

Write your full name here as a digital signature acknowledging that the information you have provided is accurate and you agree to releasing this information to Maine Outdoor School and Frenchman Bay Conservancy to ensure appropriate care for the participant. Responses will remain confidential: *

Send me a copy of my responses.

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