2018 Medical Waiver and Release

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1 2018 Medical Waiver and Release I hereby give my consent to the Summer Camps at Avon Old Farms School personnel to provide, through a medical staff of its choice, customary medical attention and emergency medical services as warranted in the course of my son/daughter s participation in the Summer Camps at Avon Old Farms School. I agree to take full responsibility for the expenses incurred as a result of such treatment. I am fully aware of and appreciate the risks, including the risk of catastrophic injury, as well as other injuries and losses associated with participation in this outdoor summer program. I further agree on behalf of myself, my heirs, and personal representatives, that selected Summer Camps at Avon Old Farms School programs, along with the directors, medical staff and counselors of this organization, or the administration or employees of the Avon Old Farms School, shall not be liable for any injury or damage occurring as a result of my son/daughter s participation in this program. Camp Participant s Full Name (Please Print) Parent/Guardian s Full Name (Please Print) Signature of Parent/Guardian Please check all camps this camper will attend this summer AOF Baseball John Gardner Hockey AOF Football Camp AOF Lacrosse AOF Soccer Camp

2 The Health History and Examination Form must be completed ANNUALLY by parents/guardians of minors or by adult campers/staff members themselves. An alternate physical and health history form may be substituted for this one. Camper Name Birthdate Sex Age Last First Initial Home Address Street & Number City State Zip Please check all camps (and camp sessions) this camper will attend this summer AOF Baseball (6/25-28) AOF Baseball (7/9-12) AOF Lacrosse (7/30-8/2) AOF Football Boarding (6/24-27) AOF Football Day (6/25-28) AOF Soccer (8/20-24) John Gardner Hockey Boarding (8/5-8/9) John Gardner Hockey Day (8/13-8/17) Health History: (Check, give appropriate dates.) Frequent Ear Infections Heart Defect/Disease Convulsions Diabetes Bleeding/Clotting Disorders Hypertension Mononucleosis Psychiatric Treatment Diseases Chicken Pox Measles German Measles Mumps Allergies (dates not needed) Hay Fever Ivy poisoning, etc. Penicillin Other Drugs Has this camper been on any medication within the last six months? If yes, please explain. Has this camper ever required any psychiatric counseling or hospitalization? Explain Operations or serious injuries (dates) Disability or chronic or recurring illness Activities encouraged or limited by physician Dietary modifications Other diseases or details of above Name of dentist / orthodontist Phone Name of family physician Phone of last physical examination Do you carry family medical/hospital insurance? If so, indicate: Carrier Policy or Group # Suggestions or health related information for camp personnel Asthma Other (Specify) Important The Box Below must be completed annually for Attendance* This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted. Authorization for Treatment: I hereby give permission to the medical personnel selected by the camp director to order X- rays, routine test, treatment and necessary transportation for me/or my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for my child as named above. The completed forms may be photocopied for trips out of camp. Signature of parent or guardian Please submit this form two weeks prior to your child beginning camp. The forms may be submitted via one of the following ways: camp@avonoldfarms.com Mail AOF Summer Camps 500 Old Farms Road

3 Avon, CT Camper Name: of Birth: Sex: Age: Physicians: Please complete all areas of this form below. Please attach a copy of the camper s immunization record. of Exam: Height: Weight: BP: Pulse: Is the camper currently under the care of a physician for any condition(s)? Yes (Please provide details below) Is the camper currently taking any medications? Yes Will the camper need to take any of these medications while at camp? Yes (Please complete the appropriate forms for self-administration of medication) Does the camper have epilepsy? Yes Does the camper have asthma? Yes Does the camper have diabetes? Yes (Please provide a plan of care and appropriate testing equipment) Please explain in the space provided below any reported loss of consciousness, convulsion, or concussion Does the camper need to follow a medically prescribed meal plan or does the camper have any dietary restrictions? Yes (Please provide details below) Does the camper have any allergies? Yes (Please provide details below) This camper (please check the appropriate box below) may participate in all camp activities may participate in some camp activities (please provide details below) may not participate in any camp activities Physician Name Please Print Physician Signature

4 Administration of Medication Policy Below is the Avon Old Farms Summer Camps Administration of Medication Policy. Please read the policy and complete the forms that follow it only if your child will need to take (prescription or over-the-counter ) medication while at camp. If you have any questions regarding this policy, please contact the Summer Camps office by phone or via . Avon Old Farms Summer Camps will keep on file the following: All Prescribed inhalers or Epi-pens or other medications with parent s consent and a doctor s signature. n-prescription oral medications with parent s consent and a doctor s signature. Parent Responsibilities It is the parent s responsibility to inform program staff upon registration that their child has a prescribed inhaler, epi-pen, or other medication. Prescription medications must be handed to the Director of First Aid by the child s parent. Medication forms are required to be signed by parent and the child s physician before the program starts. Your child will not be allowed to attend camp if the appropriate forms (attached below) are not completed. If there are any changes to the child s dosage/medication, a new set of forms must be completed by the child s physician. Medications must be in their original container and clearly labeled with the child s name. A prescription label must accompany all prescription medication. Staff Responsibilities Camp staff will maintain medications in accordance with Connecticut State Dept. of Health regulations. All medications, except for epi-pens, will be self-administered by the camper under close supervision of a camp staff member. Epi-pens will be administered by an appropriately trained camp staff member. Parents shall be notified of any administration errors by telephone by a camp staff member. The error will be documented in the child s camp record. Camp staff will keep accurate documentation of all medications administered by completing the proper paper work, which will be kept in the program director s files. Individual administration records shall include: o The date the medication was administered. o The time it was administered. o The dose that was administered. o Any comments

5 Self Administration of Medication Authorization Form Camper Name: of Birth: / / Medication: The camper named above has been instructed in the proper administration of the medication listed. We, the camper s physician and parent/guardian, request that this camper be permitted to self-administer this prescription medication. We consider him/her responsible for its administration. We authorize him/her to do so. He/she has been instructed in and understands the purpose and appropriate method, frequency, dosage, and use of his/her medication. We, the undersigned, acknowledge that we have read the Administration of Medication Policy and we agree to abide by its provisions. We, the undersigned, release the Avon Old Farms Summer Camps and its employees of any and all liability resulting from this camper s possession and self-administration of his/her medication. We acknowledge that, from this day forward, Avon Old Farms Summer Camps assumes no supervisory responsibility over the student s self-administration of the above-listed medication(s). Physician Name Please Print Physician Signature Parent/Guardian Name Please Print Parent/Guardian Signature

6 Prescription Medication Authorization Form In Connecticut, licensed Camps administering medications to children shall comply with all requirements regarding the Administration of Medications described in the CT State Statutes and Regulations. Parents/guardians requesting medication administration to their child while at camp shall provide the program with appropriate written authorization(s) and the medication before any medications are administered. Parents/guardians requesting that their child be allowed to self-administer medications shall provide the program with appropriate written authorization(s) and the medication. Medications must be in the original container and labeled with child s name, name of medication, directions for the medication s administration, and date of the prescription. All unused medication shall be destroyed if not picked up within one week following the camper s departure at the end of camp. Any change in medication, dose, or frequency will require a new form fromthe physician. The following information to be completed by a physician only Student Name of Birth / / Diagnosis Drug Name: Method/Route: Controlled Drug? Yes Dosage: Frequency of Administration: Time of Administration: If yes, DEA #: Relevant Side Effects of Medication Plan of Management for Side Effects Does the camper have any known food or drug allergies? Yes If Yes, please explain: May this medication be self-administered by the child? Yes Physician Name Please Print Telephone Number Fax Number Physician Signature

7 In order to facilitate communication in case of an emergency involving your child while he or she is at camp, please complete the following form. Camper Name: Home Phone: Mother s Name: Mother s Contact Information Cell: Office: Father s Name: Father s Contact Information Cell: Office: Emergency Contact Name: Emergency Contact Relationship: Emergency Contact Information Home: Cell: Office: Who should be contacted in case of an emergency? Please list the order in which each of the people above should be contacted and the best number to reach him or her at during camp hours

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