University of wisconsin-green bay - summer youth camps

UNIVERSITY OF WISCONSIN-GREEN BAY - SUMMER YOUTH CAMPS
HEALTH INFORMATION FORM and LIABILITY RELEASE
BOTH pages and BOTH copies of this form must be brought with the camper at check-in.

Sections I through V MUST be completed before a camper will be allowed in Camp. ABSOLUTELY NO EXCEPTIONS.
Campers are encouraged to have their own health insurance, as limited accident insurance is provided by the university.

I. NAME OF SUMMER CAMP ATTENDING _____________________________________ DATES __________________________

Camper's Name ________________________________________ Birthdate ____________________Gender ___________________
Home
Address____________________________________________________________________________________________________

Parent or Guardian _______________________________________ telephone (day) __________________(eve) _______________
Insurance Carrier Name ___________________________ Insurance Group ## and Policy ## _______________________________
Relative/Other Responsible Party ____________________________telephone (day) _________________ (eve) ________________

II: Camper’s Health Status: Has the camper ever had:
Allergies: If yes, list__________________________________________ Medication Allergies: If yes, list _________________________________ Seizure disorder Other:_____________________________________________________ Does the camper wear glasses or contacts? III. Medications:
If your child takes prescription medication please list it here. Bring the medication to check-in in its original container labeled with
the camper’s name and specific dose as prescribed by the physician. The medication will be stored in the Head Counselor’s office. All
medication with the exception of insulin, inhalers, and emergency medications will be administered by appropriate UWGB camp
health personnel. Parents: Please contact Mona Christensen, 920-465-2267 oat least two weeks prior to
the camp’s start date if a medication needs to be administered by injection.

I hereby authorize UW-GB camp staff to administer the following medications to my child.
Signature of parent or guardian date signed
If your child takes non-prescription (over-the–counter) medications for such things as allergies, headache, menstrual cramps etc.
medications will be kept in the Head Counselor’s office and administered by appropriate UWGB camp health personnel. We ask that
you sign below and indicate by () which medications we can administer to your child. DO NOT send the following medications to
camp with your child, as they will be supplied by the camp if needed.

I hereby authorize UW-GB camp staff to administer the following medications to my child.
Signature of parent or guardian date signed

IV. Immunization dates:
Tetanus/diphtheria (Td) ___________ MMR (measles, mumps, rubella) ________, ________
V. EMERGENCY AND NON-EMERGENCY MEDICAL AUTHORIZATION and LIABILITY RELEASE
I hereby authorize the University Health Service to provide non-emergency care to my child as needed. In addition, I authorize the
emergency center physician and/or the physician on call, the emergency center staff and hospital staff itself to order any surgical or
medical treatment, blood transfusions, anesthesia, or medication they may deem advisable for emergency care and treatment wit h the
exception of ____________________________________________
(if acceptable as stated, write "NONE" or leave blank) while my child is attending the University of Wisconsin-Green Bay Summer
Camp.
____________________________________________________ ________________________________________________
signature of parent or guardian
I certify that to the best of my knowledge the above information is true and correct, and the student can safely participate in the UW-Green Bay Summer Camp Program. Furthermore, as parent/guardian of a participant in the camp/clinic, I hereby state that I am aware of and accept the risk in herent in the program activity. I do hereby agree to hold harmless and indemnify the State of Wisconsin, the Board of Reg ents of the University of Wisconsin system, and the University of Wisconsin - Green Bay, their officers, agents and employees, from any and all liability, loss, damages, costs, or expenses which are sustained, incurred, or required arising out of the actions of my dependent in the course of the camp/clinic. __________________________________________ _____________________________________________ __________________________________________ _____________________________________________

Source: http://www.uwgb.edu/camps/assets/pdfs/2013/Health%20Form%202013.pdf