Camp Winchester Registration Health History and Examination Form PERSONAL INFORMATION Camper’s Name __________________________Birth date___________ Sex __ Camp Session Chosen: _____________________________________________ Age____________ Camper’s Social Security Number _____________________ Parent(s)/Guardian(s) _____________________Home Phone_______________ Home Address ____________________________________________________ Business/Cell Phone _______________________________________________ If not available in an emergency, please notify: Name ______________________________Home Phone __________________ Relationship ____________________Business/Cell Phone _________________ Name of Dentist/Orthodontist: _________________Phone: _________________ Name of Physician: ________________________ Phone: __________________ Insurance Information: Policy Holder: _______________________Policy Holder’s SS#: _____________ Name of Carrier: _____________________¬________Group ID# _____________ Address of Carrier: _________________________________________________ City/ State/ Zip: ___________________________________________________ Phone # of Carrier_______________________ Account #: _________________ Has this camper ever required any psychiatric counseling or hospitalization? ________________________________________________________________ Had operations or serious injury? ____________________ (Dates)___________ Does this camper have disabilities or recurring illnesses? _______________ FOR FEMALES: Has this camper menstruated? _________________________ If not, has she been told about it? _____________________________________ If so, is her menstrual history normal? ____ Special considerations: _____________________________________________ HEALTH HISTORY: Explain and/or give dates if applicable Frequent Ear Infections Chicken Pox __________________________________ Mononucleosis Measles ____________________________________________ Heart Defect/Disease Mumps ________________________________________ Convulsions Diabetes ______________________________________________ Nocturnal enuresis Rubella __________________________________________ Hypertension Asthma ______________________________________________ Bleeding/Clotting Disorders __________________________________________ IMMUNIZATION HISTORY Please record the date of basic immunizations and most recent booster doses: Vaccines Date Date Date Date __________________________________________________________________________________ DPT or TD or Td (Rubella Tetanus) __________________________________________________________________________________ Polio __________________________________________________________________________________ Measles __________________________________________________________________________________ Mumps __________________________________________________________________________________ Haemophilus influenza B (HIB) __________________________________________________________________________________ Other __________________________________________________________________________________ Tuberculin test given (most recent) __________________________________________________________________________________ If preferred, you may include a copy of your child’s immunization record. Health Examination by Licensed Physician: Date Examined: _____________ (within 12 months of start date of camp) Height ______________ Weight _____________ Blood pressure ____________ The camper is under the care of a physician for the following condition(s) (please include explanation of treatment): ___________________________________________________________________________________ __________________________________ Explanation of any reported loss of consciousness, convulsion, or concussion: ___________________________________________________________________________________ ___________________________________________________________________________________ RECOMMENDATION & RESTRICTIONS WHILE AT CAMP: 1 ) Swimming: This activity is conducted at the camp pool. The depth of the water is between 3 and 3-1/2 feet at all points. THERE IS NO DIVING BOARD AND NO DIVING IS PERMITTED. Do you want registrant to swim? YES _____ NO _____ 2 ) Camp Activities: Typical Activities include swimming, horseback riding, crafting, archery, B-B’s, Hiking and recreational games. If there are any events that the registrant may not participate in, please list them here. ___________________________________________________________________________________ Activities to be encouraged or limited by physician's advice:______________________ ___________________________________________________________________________________ Dietary modifications: ____________________________________________________________ ___________________________________________________________________________________ List any allergies (food, drugs, plants & insects, etc.) and please describe reaction: ____________________________________________________________________________________ ____________________________________________________________________________________ SIGNATURE of Parent or Guardian ______________________ Date:_________ I understand and agree to abide with the restrictions placed on my camp activities. Signature of minor: ___________________________________ Date:_________ THIS SECTION IS TO BE FILLED OUT ONLY IF YOUR CHILD WILL BE BRINGING MEDICATION TO CAMP. Prescribing Physician ______________Phone________________ Medication ____________________________________________ Purpose for Medication __________________________________ Dose _________ Frequency of doses _____________________ Duration_____________ Is the medication in the bottle the same as what is printed on the label?_____ Are the instructions on the label the same as above? _______ **Please make sure you have brought enough medication to last the entire duration of your campers stay.** Please give any additional information including any side effects, how long the camper has been taking this medication, etc: IMPORTANT INFORMATION: Camp Winchester is committed to conducting its programs and activities in a safe manner and holds the safety of participants in high regard. Camp Winchester continually strives to reduce risks and insists all participants follow safety rules and instructions that are designed to protect the participants’ safety. However, participants and parents/guardians of minors participating in the programs must recognize that there is an inherent risk of injury when choosing to participate in recreational activities and programs. You are solely responsible for determining if your child/ward is physically fit and/or sufficiently skilled for the activities contemplated by this agreement. It is always advisable, especially if the participant is disabled in any way or recently suffered illness, injury or impairment, to consult a physician before undertaking any physical activity. Warning of Risk Recreational activities/programs are intended to challenge and engage the physical and mental resources of each participant. Despite careful and proper preparation, instruction, medical advice, conditioning, and equipment, there is still a risk of serious injury when participating in any recreational activity/program. Depending on the particular activity, participants must understand that certain risks, dangers, and injuries due to inclement weather, slipping, falling, poor skill level or conditioning, carelessness, horseplay, unsportsmanlike conduct, premises defects, inadequate or defective equipment, inadequate supervision, instruction, and other circumstances inherent to outdoor and indoor recreational activities/programs exist. It is impossible for the Camp Winchester to guarantee absolute safety. Waiver and Release of All Claims and Assumption of Risk Please read this form carefully. By signing below you will expressly assume the risk and legal liability and waive and release all claims for injuries, damages or loss which your child/ward might sustain as a result of participating in any and all activities connected with and associated with said programs/activities (including transportation services/vehicle operation, when and if provided.) I recognize and acknowledge that there are certain risks of physical injury to participants in this program/activity, and I voluntarily agree to assume the full risk of any and all injuries, damages or loss, regardless of severity, that my child/ward may sustain as a result of said participation. I do hereby fully release and forever discharge Camp Winchester including their respective board, officers,employees,and volunteers from any and all claims for injuries, damages, or loss that my child/ward or I may have or which may accrue to me or my child/ward and arising out of, connected with, or in any way associated with these programs/activities. Participant’s Name (Please Print) _______________________________________________________ Parent or Guardian signature ____________________________________________________________ Date ________________________ Participation can be denied if the signature of the parent or guardian and date are not on this waiver. PHOTO RELEASE I hereby give Camp Winchester permission to use photo images of the above listed participant for the purpose of promoting the Camp Winchester’s programs in publications and on the Web. I agree that the images become the exclusive property of Camp Winchester and wave the rights thereto. For privacy and protection of your child/ward his or her name will not be used on the Web. ________________________________________ _________________________________ Participant (if child, parent or guardian signs) Date EQUINE ACTIVITIES SIGN THIS PARTICIPATION, ASSUMPTION OF RISK AND RELEASE Camp Winchester requires that all participants in Equine activities sign this Participation, Assumption of Risk and Release form in order to be eligible to participate in equine activities. The undersigned acknowledges and understands the following: 1. During Equine activities certain risks and dangers are present, and; 2. These risks may include physical or psychological damage and/or injury, not excluding fatality, due to accidents which may occur resulting from Equine activities. The undersigned agrees that while participating, the participant will abide by all of the policies and procedures of Camp Winchester regarding Equine activities provided the participant in order to maintain the utmost level of safety for the participant. Texas House Bill 28 took effect on September 1, 1995 and contains the following warning: WARNING UNDER TEXAS LAW (CHAPTER 87, CIVIL PRACTICE AND REMEDIES CODE), AN EQUINE PROFESSIONAL IS NOT LIABLE FOR AN INJURY TO OR THE DEATH OF A PARTICIPANT IN EQUINE ACTIVITIES RESULTING FROM THE INHERENT RISK OF EQUINE ACTIVITIES. An Equine animal is defined as a horse or pony. An Equine activity is defined as riding, handling, training, driving, assisting in the medical treatment of, being a passenger on, or assisting a participant or sponsor with an Equine animal. In consideration of the above, I have and hereby assume all of the risks of participation in Equine activities and will hold Camp Winchester and its employees, agents, trustees, officers, and affiliates harmless from any and all liability, actions, causes of actions, claims, and demands of every kind and nature whatsoever, whether for bodily injury, property damage or loss or otherwise, which my child now has or which may arise from or in connection with my partnership in Camp Winchester’s Equine program and activities. I, along with my family or heirs, understand and agree that we cannot sue Camp Winchester, its employees, board members, officers, director, and if I do, I cannot collect any money. In addition, I will pay for Camp Winchester’s attorey and court fees associated with any litigation I might bring against Camp Winchester, its employees, agents, trustees, officers, and affiliates. I also state that neither I am nor my child (if I am signing on behalf of my child) is under or will be under the influence of any chemical substance including alcohol, either at the time of signing this Agreement or at the time of participating in Equine activities. I fully understand that my child’s physical activity involves the potential risk of injury. I also understand that my child’s participation in Camp Winchester’s Equine program and activities is entirely voluntary. _____________________________________ ________________ Signature of Parent/Guardian Date In addition, should your child need medical attention that the camp nurse cannot provide, he/she will be transported to a nearby medical facility. All campers will ride in Camp Winchester vehicles or Camp Winchester’s staff’s vehicles, driven by Camp Winchester staff, or if necessary, be transported by an emergency vehicle. Your signature below demonstrates that you are aware of this necessity and that you consent to such transportation as described above. _______________________________________ ___________________ Participant’s Name (Please Print) Date _______________________________________ ___________________ Signature of Parent/Guardian Date Participation can be denied if the signature of the parent or guardian and date are not on this waiver. In such a case as your child has need to be transported to a nearby medical facility for such medical attention that the camp nurse cannot provide, your signature below will demonstrate your consent medical personnel to begin begin medical treatments for him/her _______________________________________ ___________________ Participant’s Name (Please Print) Date _______________________________________ ___________________ Signature of Parent/Guardian Date Participation can be denied if the signature of the parent or guardian and date are not on this waiver.