Farm & Arts Day Camp Health Form - Place-Based Learning Center

Thank you for submitting your application and deposit. The next step is for you to please complete and submit this form ASAP. Your child's camp application will not be considered complete until this form is submitted. We are a small camp and fill quickly, so secure your child's spot by submitting this form and, if applicable, activating the payment portal as soon as you receive our email.

Camper's Information

Name*

First Last

Camp Session

Parent/Legal Guardian 1*

First Last

Email*

Parent/Legal Guardian 1 should be contacted in case of emergency and has permission to pick up camper?*

Yes
No

Cell (preferred)/Home Phone Number*

Work Number

Medications and Immunization History

Please list all current prescribed, as-needed, and over the counter medications, supplements, vitamins, or topical ointments used by your child. Include each medication with dosage, route, schedule, and if the medication is self-carry.

Medications

*Please note: absolutely no prescription or over the counter medications, supplements, vitamins, or topical ointments can be administered without a physician order, in accordance with NYS law. All medications sent to camp with your child must be in the original prescription packaging or container. Campers 8 years or older may self-carry only the following medications with written permission from their physician certifying that the minor has been instructed in and is capable in its use, purpose, dosage, administration, and effects: Epipen, rescue inhalers, and insulin pumps.

Physicians Form

Campers may only attend once we have a Physician's Health Form completed by a licensed physician or nurse practitioner. This form must be submitted at least two weeks prior to your camper's arrival at the farm, and must be valid up till and including the last day of the camp session. Please download the physicians form by clicking the 'Download Physician's Health Form' button near the top of the page. After downloading, please give it to your health care provider to fill out, alternatively, we also accept the healthcare provider’s own physicians forms, as long as it is dated and signed by a healthcare provider. These forms can be sent to us at: [email protected] or faxed to us at: 518 672 7608

Immunization Records

Max. file size: 64 MB.

Please upload a copy of your child's immunization records with their name and camp session included or fax to 518-672-7608.

Initials

If camper has a religious exemption from immunizations, please provide a letter from parent or guardian. Use the field above to upload the letter or fax it to 518-672-7608 and initial.

Dietary Restrictions

We serve freshly made, primarily vegetarian meals prepared from local, organic sources. We are able to accommodate most dietary restrictions. Please provide as much detail as possible.

Does your child have any dietary restrictions?*

Yes
No

Allergen 1

This item can be served at a table with my child.

Yes
No

My child can consume this item

Yes
No

Reaction (please check all that apply):

Anaphylaxis
Rash/Hives/Itching/Eczema
Asthmatic/Wheezing/Nasal Congestion
Abdominal pain/diarrhea/nausea/vomiting
Swelling of the lips, face, or tongue
Tingling or itching in the mouth
Other

If other, please provide detail:

Medication or treatment (please send with your child, clearly marked with your child's name, in the original packaging). Your child's doctor must list all medications on your child's physical exam form as well.

Allergen 2

This item can be served at a table with my child.

Yes
No

My child can consume this item

Yes
No

Reaction (please check all that apply):

Anaphylaxis
Rash/Hives/Itching/Eczema
Asthmatic/Wheezing/Nasal Congestion
Abdominal pain/diarrhea/nausea/vomiting
Swelling of the lips, face, or tongue
Tingling or itching in the mouth
Other

If other, please provide detail:

Medication or treatment (please send with your child, clearly marked with your child's name, in the original packaging). Your child's doctor must list all medications on your child's physical exam form as well.

If you have any additional food allergies, please list them here with reactions and treatment.

Health History & Special Needs

Please check all that apply:*

Recent injury, incident, or illness

Please let us know if your child has had any issues within the recent past that may require us to adjust an activity here on the farm. Please provide as much detail as necessary.

Environmental Triggers

Your child will be working indoors and outdoors in a working farm environment, which includes exposure to environmental allergens (pollen, mold & weather conditions), farm animals (cattle, horses, sheep & chickens), animal housing (barns & hay lofts), and interior spaces which may have dust, mold, etc. Please indicate what your child's triggers and reactions are, and what treatment may be required.

Does your child have any environmental allergies?*

Yes
No

Triggers - please explain all in detail

Reaction - Please indicate what kind of reaction your child has

Asthma/Respiratory
Skin Irritation
Other; please explain above

Medication or treatment (please send with your child, clearly marked with your child's name, in the original packaging). Your child's doctor must list all medications on your child's physical exam form as well.

Treatment administration

Self administered
Needs assistance

Insect Stings - My child is allergic to the following insect stings/bites.*

Yes
No

Reaction

Medication or treatment (please send with your child, clearly marked with your child's name, in the original packaging). Your child's doctor must list all medications on your child's physical exam form as well.

Has your child ever been stung by a bee?*

Yes
No

Are one or more relatives allergic to stings?*

Yes
No

Permission for Providing Treatment for Emergency Care

I hereby authorize Hawthorne Valley to provide routine health care, administer medications as ordered by a physician, obtain emergency medical treatment including radiology and laboratory studies, and arrangement of transportation for the same. I agree to the release of any records necessary for medical treatment or insurance purposes. I consent to allow the physician selected by Hawthorne Valley Farm to secure and administer treatment, including hospitalization for the minor named above.

Parent/Legal Guardian Initials*

Permission for Activities

My/Our child has permission to engage in all activities including supervised swimming and incidental immersion (wading through streams) at on/off campus sites during camp unless otherwise noted by the physician or me.

Parent/Legal Guardian Initials*

Date*

Please input the answer to this math computation: 11 + 1 =*

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Comments

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