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Youth Medical Form - Extended Information (For Overnight Trips)

I, hereby declare that I am the parent or legal guardian of the above participant, and consent that he/she may participate in activities at Hoodoo Adventure Company. I certify that the above information is true and accurate, and agree to advise Hoodoo Adventure Company, in writing, of any change to the medical condition of the person listed above. I understand that unless Hoodoo Adventure Company hears from me otherwise, they will assume all medical information is unchanged from the date of this agreement.

October 27, 2021

 

Important Disclosure Information:

Information collected here is considered to be confidential and will be shared amongst healthcare providers (such as Emergency Health Care Providers, Walk-In Clinics, etc). This information will only be shared with Hoodoo Staff on a strict need-to-know basis to ensure the physical and mental well being of my child.
To the best of my knowledge, my child is in good health. I will notify Hoodoo Adventures in writing prior to arrival if there is any change in my child’s health, or if he or she is exposed to any communicable disease within 3 weeks prior to the camp. In the case of a medical emergency, I understand that every effort will be made to contact parents or guardians. In the event that I cannot be reached, I hereby give permission to Hoodoo Adventures to facilitate proper care for my child such as hospitalization, securing proper treatment, order injection, anesthesia, or surgery for my child as named above. I agree to reimburse Hoodoo Adventures for any prescriptions or medical expenses incurred for this camper.

I will submit any changes to this health form in writing to Hoodoo Adventures prior to arrival.

October 27, 2021

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

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

Emergency Contact's Name*

Emergency Contact's Phone Number*
Doctor's Information:

Doctor's Name:

Doctor's Phone Number:
Medical Needs and Information:
Does this child have life threatening allergies?*
No
Yes

If yes, please attach additional Anaphylaxis form.

Does your child have any non-life threatening allergies?*
No
Yes

If yes, please specify
Does this child have asthma?*
No
Yes
If yes, how severe?
Mild
Moderate
Severe
Activity Induced

Please detail medications and treatment plan:

**If your child requires an epi-pen or inhaler please leave them with the instructor and discuss this plan with your child and the instructor**

Health History:
Has your child experienced, currently experiencing, taking medication, or seeking treatment for any of the following:
Back/Neck Pain or Injury
Behavioral Issues
Blackout/Fainting
Bleeding Disorders
Chest Pains
Chrons/Colitis/IBS
Concussions
Developmental or Learning Disabilities
Diabetes
Epilepsy/Seizures
Fetal Alcohol Syndrome
Headaches/Migraines
Heart/Kidney/Organ Conditions
Motion Sickness
Nosebleeds
Sprains/Strains/Fractures
Other

If Other, please explain:
Does this child have a current tetanus immunization?:*
No
Yes
Does this child have any limitations to participation? (Physical, emotional, social or otherwise that will affect their enjoyment of the program)*
No
Yes

If yes, please explain:
May the following over-the-counter medications be administered to your child if deemed necessary by Wilderness First Responder certified Instructors?
Acetaminophen (Tylenol)
Antacids
Antihistamines (Benadryl)
Gravol
Ibuprofen (Advil)
None
Emotional Considerations:
In the past year have there been any changes in the home or family?
Birth
Marriage
Divorce
Separation
Death
Other
None
Does your child make friends easily with..
Younger Kids
Older Kids
Same Age
Adults
Is your child...
Eager to Attend
Nervous or Anxious to Attend
Urged by Parents or Guardian to Attend
Does this child have any other emotional needs or considerations?*
No
Yes

If yes, please describe:
Dietary Needs & Additional Medical Information:
Does this child have any dietary restrictions:
Vegetarian
Vegan
Lactose Intolerant
Gluten Intolerance/Celiac
Other

If other, please specify
Will your child be undergoing any dietary or medical treatments while at camp?*
No
Yes

If yes, please specify. Explain Treatment, Dosage, etc.

**Please leave all medications with the instructor on departure day of their overnight expedition**


Health History:
Has your child ever experienced, or are they currently experiencing, any of the following which may affect their overnight experience?
Athlete's Foot
Bedwetting
Dental braces/Caps/Bridges
Ear Infections
Eating Disorders
Glasses or Contacts
Homesickness
Mental Health Concern (Depression/Anxiety/Etc)
Menstruation Concerns
Nightmares/Terrors
Sinus Infection
Skin Concerns or Conditions
Sleepwalking
Urinary Tract Infection
Other

If other, please explain:

Is there any other information you would like to disclose with Hoodoo Adventures' Staff?
Health History Information and Treatment Notes:

Please describe any treatment, medication dosage & timing, or additional notes with regards to your child's health history:
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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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