TDC Health Form

Signee Information

First Name *

Last Name *

Your Date of Birth *

Phone *

Email Address *

Address *

Address Line 2

City *

State *

Zip *

Child Pick Up

I authorize the following people, other than myself, to pick up my child(ren) from Talkeetna Discovery Camp:

Name and Phone Number

Health History

Please Check the diseases of condiditons the particiapnt has or has had in the past:*
Chicken Pox
Measles
Mumps
Strep Throat
Rheumatic Fever
Skin Conditions
Headaches
Dizziness or fainting
Emotional/Mental Illness
Ashtma
Convulsions
Diabetes
Surgeries
Hernia
Hay Fever
Chronic Illness
Blood Disorder/Anemia
Heart disease/arrhythmia
Nervous System Problems
Hearing problems
Mouth/teeth/gum problems
Eye or vision problems
Intestinal Disorders
Broken Bones
Dislocations
None of the above

If you checked any above please provide more information below

Allergies:*
Food
Drug
Bee Stings
Insect Bites
Penicillin
None
Other

Please provide details on treatment and history of any allergies

Does your child have any mental, emotional, or physical disorder not listed above that we should be aware of? If yes please provide a description below.*

Is your child currently taking any medications or under the supervision of a doctor for any conditions? If so, what medications and for what conditions?*

Is your child currently taking any over the counter medications? If so, list all medications and for what purpose they are used. *

Does your child have any dietary restrictions or special regimens that we should be aware of?*

Safety is our primary concern, but active young people will on occasion find ways to injure themselves. Are there any activities that your child should be discouraged from participating in because of health concerns or parental desires? If yes please describe.*

Please check off medications you authorize an instructor to administer to your child if deemed necessary:*
Ibuprofen (Advil)
Acetaminophen (Tylenol)
Antihistamine (Benadryl)

If a medication is not authorized, we will call you for verbal permission to administer the medication if deemed necessary. Please note: this will create a delay in being able to administer the medication.

Consent for Emergency Medical or Surgical Care

In the rare event of an emergency, I hereby give permission to the medical personnel selected by the camp to provide routine health care; to administer medications; to order x-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me/or my child. In the event I cannot be reached in an emergency, I hereby give my permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person listed above. This completed form may be photocopied for trips out of camp. All information is strictly confidential. Talkeetna Discovery Camp does not cover accident insurance coverage for participants; you must carry your own accident insurance coverage. It is understood that conscientious effort will be made to locate me or my child’s other parent or legal guardian in case of emergency. I understand my obligation to keep Talkeetna Discovery Camp staff informed of my whereabouts during camp. I will assume the cost of necessary medical or surgical care. I authorize the following information for insurance purposes.

Name of Physician *

Phone Number*

Clinic*

Primary Health Insurance Company*

Policy Number *

Authorizations

My son/daughter/dependent has permission to participate in all Talkeetna Discovery Camp activities, except those noted by me. I recognize that Talkeetna Discovery Camp involves young people in a variety of adventurous outdoor activities and in a variety of outdoor settings in all kinds of weather and conditions and that accidental injury or illness may result. I assume the inherent risks including but not limited to wildlife encounters and inclement weather and authorize my child’s participation. Children will be transported between in vans operated by Denali Education Center and partner organization staff. Vans are equipped with seat belts that participants are required to wear. I authorize my child to be transported in the manners described.

Please enter participants' full names:

First Name *

Last Name *

Date of Birth *

Add Another Name

Sign Here

By clicking 'I Agree' below, you agree that you have read and agree with the terms of the waiver and that the information you provided is accurate. You furthermore agree that your submission of this form, via the 'I Agree' button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.