Koinonia Camp Medical Form - Firefly Consulting Services

Koinonia Nature Camp Child Medical Release Form

Thank you for submitting your Nature Camp Registration! The next step is to complete a medical release form for each child registered.

Please complete and submit the below form separately for each child that you have registered for nature camp. This is the only record of medical information we have on your child so it is important that you fill this out honestly and completely. It is for your child’s well-being and safety.

Once this form is submitted, you will receive an email confirming this information plus an attached Health History document for your child. You must sign the attached document and send it back to us, either via email to program@koinoniany.org or via mail to Koinonia Nature Camp, 165 Lakeview Drive Road, Highland Lake, NY 12743.

All signed documents must be received at least one week prior to your child’s first day of camp. Please note that no participant will be accepted into the program until all information is completed, signed, and given to our office.

Your Email Address *
Child’s Full Name *
Date of Most Recent Physical: *
Are immunizations up to date?*
Does your child have asthma?*
Does your child have any food allergies?*
If yes, which foods?
Is your child allergic to insect bites or stings?*
Is your child allergic to latex?*
Is your child allergic to any medications?*
If yes, which medications?

Is your child presently taking prescription medications for any health reasons? If yes, please explain:

Will these prescription medications be taken while they are on camp grounds?*

Is your child presently taking over-the-counter or non-prescription medications for any health reasons? If yes, please explain and list all medications:

According to New York State Childcare Regulations, prescription and over-the-counter medication may be administered only upon written permission of the parent and written instructions from a health care provider stating that the program may administer such medication and specifying the circumstances, if any, under which the medication or prescription must not be administered. Medication must be in the original container labeled with the child’s complete name, the medication name, recommended dosage, time intervals for administration, method of administration, expiration date and, for prescription medication, the prescriber’s name and license number. Are there any restrictions your child is presently under, or will be under during the camp program, that we should be aware of? Are there any special health or dietary needs or problems we should be aware of?