Arrowhead ranch outdoor science school

EMERGENCY CONTACT (NAME & RELATIONSHIP) INFORMATION ABOUT YOUR CHILD: TO PROTECT YOUR CHILD FROM POSSIBLE EMBARRASSMENT, BUT NOT TO EXCLUDE HIM/HER FROM THE PROGRAM, THE FOLLOWING INFORMATION IS NEEDED: DOES YOUR CHILD WALK IN HIS/HER SLEEP, WET THE BED AT NIGHT, ETC? IF YES, PLEASE SPECIFY ARE THERE ANY FACTORS WHICH MIGHT AFFECT THE HEALTH OF YOUR CHILD; SUCH AS ASTHMA, ALLERGIES, ETC? HAS YOUR CHILD BEEN EXPOSED TO ANY COMMUNICABLE DISEASES (MEASLES, MUMPS, CHICKEN POX, ETC.) WITHIN THE PAST 21 DAYS? IS THERE ANYTHING WHICH MAY CAUSE AN ALLERGIC REACTION, LIKE A BEE STING, PENICILLIN, ETC? ARE YOU AWARE OF ANY HEALTH FACTOR(S) THAT WOULD MAKE IT ADVISABLE FOR YOUR CHILD TO FOLLOW A LIMITED PROGRAM OF PHYSICAL ACTIVITY? PLEASE COMPLETE THE NAME, ADDRESS, AND PHONE NUMBER OF YOUR CHILD’S PHYSICIAN IF YOUR CHILD HAS ANY SPECIAL DIETARY NEEDS OR FOOD RESTRICTIONS, PLEASE LIST THEM AND ADVISE US OF ANY ALTERNATIVE OR OPTION FOR THEIR STAY AT SCIENCE SCHOOL IN THE EVENT OF A MINOR ILLNESS (SUCH AS COLD OR HEADACHE, DO YOU AUTHORIZE THE ADMINISTRATION TO YOUR CHILD OF COMMON REMEDIES SUCH AS MOTRIN, JUNIOR TYLENOL. PEPTO BISMOL, IBUPROFEN, MIDOL, NEOSPORIN, CHAPSTICK AND THROAT LOZENGES, IN DOSAGES APPROPRIATE TO HIS/HER NEEDS. YES BOTH SIDES OF THIS FORM MUST BE COMPLETED IN THE EVENT OF AN ALLERGIC REACTION, DO YOU GIVE PERMISSION TO ARROWHEAD KIDS CAMP MEDICAL PERSONNEL TO ADMINISTER BENADRYL TO YOUR CHILD? YES . IF YOUR CHILD IS ALLERGIC TO BENADRYL, PLEASE NOTE IF YOUR CHILD WILL BE TAKING PRESCRIPTION MEDICATION, PLEASE INDICATE BELOW: MEDICATION ALL MEDICATIONS MUST BE IN THE ORIGINAL CONTAINER, ENCLOSED IN A PLASTIC BAG, CLEARLY LABELED WITH ALL PERTINENT INFORMATION, INCLUDING THE CHILD’S NAME AND GIVEN TO THE MEDIC UPON ARRIVAL. HEALTH HISTORY IN CASE OF EMERGENCY, IF WE, THE PARENTS OR LEGAL GUARDIANS OF THE ABOVE NAMES STUDENT, CANNOT BE REACHED, WE DO AGREE THAT X-RAY EXAMINATION, ANESTHETIC, MEDICAL OR SURGICAL DIAGNOSIS AND/OR TREATMENT, AND HOSPITAL CARE MAY BE RENDERED TO SUCH MINOR UNDER THE GENERAL OR SPECIAL SUPERVISION AND ON THE ADVICE OF A DULY LICENSED PHYSICIAN OR SURGEON; OR THAT ANESTHETIC, DENTAL OR SURGICAL DIAGNOSIS AND /OR TREATMENT, AND HOSPITAL CARE MAY BE RENDERED TO SUCH MINOR BY A DULY LICENSED DENTIST. WHEN OR IF SUCH OCCASION ARISES, OR TRANSPORTATION OR MEDICAL ATTENTION BECOMES NECESSARY, IT IS HEREBY AUTHORIZED WITHIN THE ABOVE PROVISIONS AND LIMITATIONS. FURTHER, WE AGREE TO HOLD HARMLESS AND INDEMNIFY ARROWHEAD KIDS CAMP, THEIR OFFICERS, AGENTS, AND EMPLOYEES IF THE AFORE-MENTIONED MEDICAL OR DENTAL TREATMENT IS RENDERED TO SAID MINOR CHILD. I HAVE REVIEWED AND UNDERSTAND THE CONDITIONS ON THIS FORM AND GIVE MY CONSENT FOR MY SON/DAUGHTER TO PARTICIPATE. IN ADDITION, I AM AWARE OF THE EDUCATION CODE SECTION 35330, WHICH PROVIDES THAT ALL PERSONS MAKING A FIELD TRIP OR EXCURSION ARE DEEMED TO HAVE WAIVED ALL CLAIMS AGAINST THE CAMP OR SCHOOL FOR INJURY, ACCIDENT OR ILLNESS OCCURRING DURING OR BY REASON OF THE TRIP OR EXCURSION. I AGREE TO AND WILL PICK UP MY SON/DAUGHTER IN THE EVENT THEY BECOME ILL OR HAVE A BEHAVIOR PROBLEM.

Source: http://www.tustin.k12.ca.us/cms/lib02/CA01001904/Centricity/Domain/30/Outdoor%20Ed%20Health%20History%20Form%20.pdf