Sing Minnesota Health and Consent Form
Camper's name *
Your answer
Camper's age *
Your answer
Camper's birth date *
Your answer
Camper's address *
Your answer
Does the child have medical insurance coverage? *
Please list type of plan, company and policy number(s)
Your answer
Does the child have any drug or food allergies? *
If yes, please give pertinent details: What drugs or foods? What type of reaction occurs? How long ago did the reaction occur?
Your answer
Is the child allergic to bee stings? *
If yes, what happens if the child is stung?
Your answer
Does the child have any of the following conditions (please check box if yes)?
Does the child have any other medical conditions which may limit his or her participation in any camp activities, or which should be of special concern to the staff?
If yes, please explain in detail
Your answer
IMMUNIZATIONS
Please list the date of the more recent vaccination, indicate "Up to Date," or write "Do Not Vaccinate."
M/M/R *
Your answer
Hepatitis B *
Your answer
Polio *
Your answer
DPT/TD
Your answer
Chicken Pox *
Your answer
CONTACT INFORMATION
Physician's name and phone *
Your answer
Name(s) of parent or guardian *
Your answer
Best phone number(s) for parent/guardian *
Your answer
In Case of Emergency Contact -- If parent/guardian cannot be reached, please contact: *
Please include: Name, relationship to camper and phone number
Your answer
PARENT/GUARDIAN PERMISSION FOR PRESCRIPTION AND OVER-THE-COUNTER MEDICATIONS
Sing Minnesota staff must have consent from a camper's parent or guardian for each over-the-counter and prescription medication the child takes. Please indicate which over-the-counter medications you approve of, do not approve of, if your child is allergic to any of them, or if they have never taken the medication.
Current weight
For dosing purposes
Your answer
*
Yes, Allowed
No, not allowed
Allergic
Yes, Chewable Form Needed
Acetaminophen (ex. Tylenol)
Ibuprofen (ex. Motrin or Advil)
Pseudoephedrine (ex. Sudafed)
Bismuth Subsalicylate (ex. Pepto Bismol)
Loperamide (ex. Imodium AD)
Dextromethorphan (cough suppressant)
Diphenhydramine (ex. Benadryl)
Dimenhydrinate (ex. Dramamine)
Calcium Carbonate (ex. Tums)
Medications during camp
Please list all prescription and over-the-counter medications the camper will take at Sing Minnesota. Include topical preparations, as well as dosage for all medications. Medications must be turned in to the staff, and will be administered according to the instructions provided by the parent or guardian.
Your answer
PARENT/GUARDIAN CONSENT FOR EMERGENCY MEDICAL CARE
I give permission for the camper named above to receive emergency medical or surgical treatment and to be hospitalized if necessary. I understand that every attempt will be made to contact me or the In Case of Emergency contact named above before such action is taken.
Parent/Guardian signature *
Your typed name constitutes sufficient signature
Your answer
Date *
Your answer
PHOTO RELEASE
I give permission for Sing Minnesota and the Minnesota Boychoir to use photos/images of my child for promotional purposes
Parent/Guardian signature
Your typed name constitutes sufficient signature
Your answer
Date
Your answer
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