Astro Camp Medical Information
AND
Picture Release Form
1.Child's Name:______
2. Does your child suffer from any of the following conditions? (Please circle all those that apply)
Asthma, Hyperactivity, Bronchitis, Nose Bleeds, Sunburns Easily, Dizziness, Diabetes, Claustrophobia,
Allergies (please list) ______
3. Will you be sending any type of medication with your child? (circle one) YES NO
4. Please give us your family doctor's name, address and phone number.
Name ______
Address ______
City/State/Zip ______
Phone ______
5. NEW MEDICATION ADMINISTRATION GUIDELINES(PLEASE READ CAREFULLY) Due to complicated changes in the State Policy for administering medications we find that we are unable to continue our previous tradition of handling and administering your child's medication while they are attending Astro Camp. However, we would be more than happy to see that they are taken. If you are sending prescription medication with your son or daughter would you please provide in the space below a list of the name(s) of the medication, times that the medication must be taken each day, and the dosage. We will remind your child to take their meds at scheduled times.
6. Are there any special instructions regarding your child that we need to be aware of? Please list any activities that you feel your child should not participate in (e.g. swimming, excessive speed rides, etc.)
7. As a parent/guardian of the above mentioned child, I certify that this information is accurate to the best of my knowledge. I have read and understand the new Medication Administration Policy. I further understand that the safety of every child who attends Astro Camp will be a high priority and give my permission for the above named child to participate in all activities, unless listed in part #6, and will not hold the Astro Camp staff nor the Ogden City School District responsible for injuries or damages resulting from my child’s participation in Astro Camp activities. Field Trip transportation during each camp will be furnished by school buses.
8. PICTURE RELEASE - During the course of the summer we will be taking photos of some of the activities to put on the Astro Camp Website. There will be no use of students names, As a service to you, some photos will be made available on the website by session date.You may download these pictures for personal use.
Please put a check next to the appropriate statement.
______Yes, my child's picture may be placed on the Astro Camp Website
______No, I do not want my child's picture placed on the Astro Camp Website
Parent’s Signature ______Date ______