middle school retreat registration forms

Middle School Retreat July 26 ± 28, 2011 PARTICIPANT HEALTHFORM Page 1/2 Attendance dates: from: _____________ to _______________ Participant Name: __________________________________ _____________ First Middle Last Male Female Birth Date ___________ Age on arrival at program ____ Month/Day/Year P a r t i c i p a t a m e : ( F o C a m p U s e ) C a b i n o r G r o u p ( F o r P r o g r a m U s e ) S e s s i o C o d e ( s ) F i r s t M i d d l e L a s t Mail this form to the address below by July 15, 2011 W SU/OMK 4-H 2606 W Pioneer Puyallup, WA 98371 To Parent(s)/Guardian(s): Please follow the instructions be low. Attach additional information if needed. 1. C omplete pages 1, 2 and 3 of this f orm (and make a copy for yourself). 2. Send the original, signed form to program by requested date. Participant Home Address: ____________ Street Address City State Zip Code Parent/guardian with residential placement and/or decision-making authority in the event of illness or injury: Relationship Name:_____________ _ to Participant: ________ Preferred Phones: (______) _______________ (______) ______________ Email: __________________ ___________ Home Address: __________________ __________________ ___________________ (If different from above) Street Address City State Zip Code Second parent/guardian with legal custody to be contacted in case of illness or injury: Relationship Name:_____________ _ to Participant: ___________ Preferred Phones: (______) _________________ (______) _______________ E mail: _____________________________ Additional parent/guardian to be contacted in case of illness or injury: Relationship Name:_____________ __ to Participant: ___________ Preferred Phones : (______) _________________ (______) _____ ____________ Email: _____________________________ Allergies: No known allergies. This participant is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other (Please describe below what the participant is allergic to and the reaction seen, i n detail. Please describe preventative or responsive measures.) This participant has a life-threatening allergy. An emergency care plan signe d by physician is required. Diet, Nutrition: This participant ea ts a regular diet. This participant ea ts a vegetarian diet (describe details below). This participant has special food needs. (Please describe below.) Immunizations: My child is up-to-date on his/her immunizations and tetanus shots as required by Washington State law. My child has an immuniza tion exemption on file with his/her school. I understand and accept the risks to my child from not being fully immunized. Medication: We will be unable to a dminister medication to children. If your child requires a dosage during activity/event hours, please make appropriate arrangements. Medication´ is any s ubstance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. All medications must be in their original co ntainers. Prescriptions must have the child¶s name and how the medication should be given printed on the prescription container. Please s end only those medications that are necessary. Medications Currently being taken: (must list) This participant will not take any daily medications while attending the activiti es. This participant will be self-administering the following daily medication(s) while attending the activities. 1 1 Note: These provisions regarding administration of medication shall not abrogate minors¶ rights to provide their own consent to certain services under Washington law.

middle school retreat registration forms

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