Region 1 LTC Registration

Region1_LTC

Attendee Name(Required)

First Last

Attendee Date of Birth(Required)

State or Providence(Required)

Attendee Age(Required)

Attendee Gender

Attendee Height

Attendee Weight

Attendee Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent / Guardian Name

First Last

Parent / Guardian Phone

Parent / Guardian Email

Parent / Guardian Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Attendee Phone

Attendee Email

Attendee Health/Accident Insurance Company

Attendee Policy Number

You will need a picture of your insurance card (instructions post form submission).

Complete for participants under the age of 18:

Adults Authorized to Take Youth to and From LTC You must designate at least one adult. Please include a phone number.

Name

First Last

Phone

Name

First Last

Phone

Adults NOT Authorized to Take Youth to and From LTC

Name

First Last

Phone

Name

First Last

Phone

Part A: Informed Consent, Release Agreement, and Authorization

List participant restrictions, if any:

I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity. The participant has permission to engage in all activities, except as specifically noted by me or the health-care provider. If the participant is under the age of 18, a parent or guardian’s signature is required.

Participant's Signature:

Date

Parent/guardian signature for youth:

Date

Part B1: Health History

In case of emergency, notify the person below

Emergency Contact Name

First Last

Emergency Contact Relationship

Emergency Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency POC Cell Phone

Emergency POC Alternate Phone

History

Health History – Do you currently have or have you ever been treated for any of the following?

Last HbA1c Percentage and Date(Required)

Insulin Pump(Required)

Yes

Last Asthma Attack Date(Required)

Last Seizure Date(Required)

CPAP(Required)

Yes

List any other medical conditions not covered above, all surgeries, hospitalizations, and last surgery date:

Part B2

This section requires a physical download. Instruction link provided upon successful form submission.

Part C Pre-Participation Physical

This section requires a physical download. Instruction link provided upon successful form submission.

Part D-NH: Permission to Possess & Use Epinephrine Auto-Injector and/or Asthma Inhaler

This section requires a physical download. Instruction link provided upon successful form submission.

Part E: OTC Supplemental Information

The following over-the-counter medications will be available through the health officer if a participant becomes ill during LTC. Please check the medications your child may be given if needed. Medicine will be administered per package instructions. Please send your child’s own supply of over the counter medicine ( in the original container) if they are a normal routine or taken daily.

NOTE: Failure to complete this section or to authorize any OTC Medication can result in an uncomfortable experience at camp. If you have any questions regarding administration of medications, please contact camp personnel.

Check all that are authorized

Acetaminophen (Tylenol)

Ibuprofen (Motrin)

Benadryl/Antihistamine

Anti-Diarrhea

Check all that are authorized

Pepto Bismol

Decongestant

Antacid

Swimmer’s Ear

Check all that are authorized

Bug Spray

After Bite

Eye Drops

Sun Block

Check all that are authorized

Sun Burn Cream (Aloe)

Calamine Lotion

Antibiotic Ointment

PART F: Authorization to Administer Medication to a Camper

To be completed by parent/guardian for all participants under the age of 18

All medications brought to camp, including over the counter, epinephrine injectors and inhalers must be included on this authorization.

All medications must be in original prescription or retail container. All medication must be given by the health supervisor/nurse. This form must be filled completely.

Please make sure that if any prescriptions are added or changed for the first day of camp – that you have updated this form to include those changes.

Name of Licensed Perscriber

Perscriber Phone

Perscriber Emergency Phone