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Summer Medical Condition, Allergy & Medication Action Plan Form

Please complete only if you have indicated that your child has a medical condition,allergy or sensitivity, which may or may not require treatment. The following completed information will be kept on file with Baroody Camps, Inc. for Summer Camps.

*You must fill out one (1) form per allergy camper*

NUT ALLERGY CAMPERS -During both lunch and snack breaks, to prevent contact with any nut products, we have a designated nut-free area. We require our campers who have nut allergies, peanut or tree nut, to eat meals in our nut-free area during snack and lunch time. We take special care to ensure that campers with allergies do notfeel alienated during our eating breaks, and we encourage these campers to invite a friend to sit with them at lunch, as long as their friends lunch is also nut-free. We require at least onecounselor to be seated at the nut-free table during all eating times.At the end of each eating period, we require all campers to wash their hands with soap and warm water to ensure they thoroughly clean their hands prior to their next activity.

*Please note:All Baroody Camps, Inc. employees CPR and First Aid certified. Our On-Site Directorsare all Medication Administration Trained with an emphasis in storing and administering medications to children.

 

*This information is required to be updated each Summer*

Please select who will be participating in camps...
Minor
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First Camper's Name

First Name*

Last Name*

Phone*
First Camper's Age Acknowledgment*
First Camper's Date of Birth*
I certify that I am 18 years of age or older
First Camper's Medical condition, Allergy, Sensitivity Information:

Please list any medical conditions, allergies or sensitivities your child may have: *
The symptoms my child presents with are:*

Please list any and all symptoms your child presents with: (please be specific) *
My child has asthma*
No
Yes
First Camper's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
ALLERGY ACTION PLAN
Please select one of the following (if you select one of the first two options involving epinephrine, please complete the following Medication Authorization Form): *
If checked, give epinephrine for any severe symptoms after suspected or known ingestion.
If checked, give epinephrine immediately for ANY symptoms if the allergen was definitely eaten.
If checked, give epinephrine immediately for ANY symptoms if the allergen was likely eaten.
If checked, give epinephrine immediately if the allergen was definitely eaten, even if no symptoms are noted.
If checked, give antihistamine (i.e. Benadryl) immediately for ANY symptoms if the allergen was likely eaten
If checked, give antihistamine (i.e. Benadryl) immediately if the allergen was definitely eaten, even if no symptoms are noted.
My child's physician does not require medication or action for my child's medical condition or allergy/sensitivity.
MEDICATION AUTHORIZATION FORM (for Prescription and Non-prescription Medications)

Camper's Name *
My child's medical condition, allergy, or sensitivity requires medication:*
No
Yes

Name of medication(s)
This is a long-term medication (lasting longer than 10 working days)*
No
Yes

**If this authorization is for long-term medication (lasting more than 10 working days), all information below must be submitted by the parent/guardian AND in writing from your child's physician.**


Dosage to be administered

Times to be administered

Special instructions (if any):

This authorization is effective from: (start date)

This authorization is effective from: (end date)
By signing this waiver, I hereby acknowledge that the above information has been answered to the best of my knowledge. I understand that Baroody Camps must receive written authorization from your child's physician for long term medications (lasting more than 10 working days) or this form must be renewed by the parent/guardian every 10 working days. I agree to release, indemnify and hold harmless, Baroody Camps, Inc., its President, the School, its agents, officers, and employees from lawsuits, claims, expenses, demands, or actions, etc. against them for administering any medications. I have read the procedures outlined on this form and assume responsibility as required.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Medical condition, Allergy, Sensitivity Information:

Please list any medical conditions, allergies or sensitivities your child may have: *
The symptoms my child presents with are:*

Please list any and all symptoms your child presents with: (please be specific) *
My child has asthma*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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