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* HEALTH HISTORY & EMERGENCY INFORMATION
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* Pony and Critter Camp *
Down on the Farm
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17220 Keystone Ave., Hugo, MN 55038
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Phone 651-433-5640
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| Name:______________________________________ Birth date:____________ Age:_____ M___ F___ |
| Home Address:___________________________Social Security Nbr of Participant__________________ |
| Custodial parent/guardian__________________________________Phone_________________________ |
| 2nd parent/guardian______________________________________Phone_________________________ |
| If not available in an emergency, notify: Name________________________________________________ |
| Relationship:__________ Address:___________________________________Phone:_______________ |
| Insurance Information: Is the participant covered by family medical/hospital insurance? |
| _____Yes ______No |
| If so, indicate carrier or plan name___________________________Group #_______________________ |
| Name of insured______________________________________________________________________ |
| Social security number of policy holder or Insurance ID number___________________________________ |
| Relation to participant__________________________________________________________________ |
| *********************************************************************************** |
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* IMPORTANT - THESE BOXES MUST
BE COMPLETE FOR ATTENDANCE *
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| Parent/Guardian Authorization This health history is correct as far as I know. The person herein described has permission to engage in all camp activities except any noted. I hereby give permission to the camp to provide routine health care, administer prescribed medications, and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for insurance purposes. I give permission to the camp to arrange necessary related transportation for me/my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trip out of camp. We hereby release Down on the Farm, Inc. of any liability exceeding insurance coverage. |
| Signature of Parent/Guardian_____________________________________________________________ |
| Printed Name:___________________________________________ Date:________________________ |
| I also understand and agree to abide by any restrictions placed on my participation in camp activities. |
| Signature of participant:_________________________________________________________________ |
| *** this section must be complete for attendance *** |
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| Date of last tetanus immunization:__________________________________________________________ |
| List all Allergies known:________________________________________________________________ |
| MEDICATIONS BEING TAKEN: Please list ALL medications (including over-the-counter or non-prescription drugs) taken routinely. Identify the prescribing physician (if prescription drug), the name of medication, the dosage, and frequency of administration _____________________________ ___________________________________________________________________________________ |
| ___________________________________________________________________________________ |
| List any RESTRICTIONS, if any (explain any restrictions to activities)_____________________________ |
| ___________________________________________________________________________________ |
| GENERAL QUESTIONS: (Explain "yes" answers below) |
| Has/does the participant: |
| * Ever passed out during or after exercise or by dizzy? ___Yes ___No |
| * Have asthma? ___Yes ___No |
| * Ever had seizures? ___Yes ___No |
| * Have diabetes? ___Yes ___No |
| * Ever had emotional difficulties for which professional help was sought? ___Yes ___No |
| Use this space to provide any additional information about the participant's behavior and physical, emotional, or mental health about which the camp should be aware:_________________________________________ |
| ___________________________________________________________________________________ |
| ___________________________________________________________________________________ |
| Name of family physician:_____________________________________Phone______________________ |
| Name of clinic and address______________________________________________________________ |
| please print and complete form and mail it to: |
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Down on the Farm, Inc. |