Saline County Sheriff's Office

G.R.E.A.T. Summer Camp

2009

Rock Springs Health and Participation Form

 Camp Group                                                                                                                                               

 Participant’s Name                                                                                                             

 Health

List below any physical condition the supervisor, EMT, nurse or adult sponsor should be aware of.  (Reporting conditions will not prevent a child from attending and will be kept confidential.)  Check conditions present and list any pertinent information.

      insect stings                                   diabetes                                  heart condition                                   ear infection

      fainting spells                     headaches                  allergies (please explain)                                                                                                                                                                

Allergic to any drugs (please list)                                                                                                                                                                                                                                            

Prescribed medicines presently taking                                                                                               

Date of last tetanus immunization                                                                                                    

Other conditions                                                                                                                                

Participation

Rock Springs instructional staff is trained to provide the safest activities possible.  I understand the campers will be closely supervised and agree that the supervisors, sponsors and Rock Springs 4-H Center is not responsible in case of injury or illness.  I further understand that first aid will be available and that should a serious injury or illness occur, medical or hospital care will be provided.  I realize the supervisors will notify me in case of serious injury or illness.  However, should they be unable to contact me, I hereby grant my permission and consent for emergency medical or surgical care to be given, as determined necessary by a licensed physician.  I give permission to Rock Springs 4-H Center, the Kansas 4-H Foundation and the Kansas 4-H Extension program to use pictures taken of my minor child while participating in activities at Rock Springs 4-H Center.  I understand these photos may be used for the promotion of Rock Springs and cannot be sold or distributed to any other entity.

(Participant if over 18)

Parent or guardian’s signature                                                                     

I specifically agree to hold Rock Springs 4-H Center harmless as to any claim for damages for any accident or injury of any kind resulting from the participation of my minor ward in Rock Springs activities including programs involving horses, and this “hold harmless guarantee” is specifically granted in consideration of the services by Rock Springs 4-H Center.

(Participant if over 18)

Parent or guardian’s signature                                                                     

Address                                                                                                                               Date                                                  

In case of an Emergency please notify:                                                                                    

Day Phone #                                                                        Evening Phone #