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Farm & Arts Day Camp Health Form

To make a tax deductible donation to support a camper from the Hudson, NY area, please click the button below, and choose “Summer Camp Scholarships” from the Designation drop down menu. Thank you so much for your generosity!

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.
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:*
- Seizure Disorder
- Glasses/Contact Lenses
- GI Issues
- Eating Disorders
- Nebulizer
- Sleep Walking
- Bedwetting
- Diabetes
- Catheters or Stents
- Hearing Aids/Impairment
- N/A
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*
MM slash DD slash YYYY
Please input the answer to this math computation: 11 + 1 =*
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Name
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