Medical Release Form | Westport River

Participant Information

Child's Full Name (Last, First)

Nickname

Primary Language

Birthday

Gender

Age

Parent or Guardian Name

Full Name (Last, First)

Work Phone

Cell Phone

Email Address

Street Address

City or Town

State

Zip Code

Mailing Address (if different)

Second Parent or Guardian Name

Full Name (Last, First)

Work Phone

Cell Phone

Email Address

Street Address

City or Town

State

Zip Code

Mailing Address (if different)

Physician & Insurance Information

Child's Physician

Health Insurance Provider

Subscriber Name:

Physician's Phone Number

Insurance Provider's Phone Number

Certificate Number

Group Number

Emergency Contact
Please list up to three additional contacts that should be reached in case parents or guardians cannot be reached in the event of an emergency

Full Name (Last, First)

Contact's Phone Number

Relationship:

Participant's General Health History
Please list any medical conditions your child has in order to allow our teachers to provide the safest and best possible experience for them

Allergies
i.e. food, medicine, seasonal, environmental, etc.

Please list all allergies and describe reactions

Medical Information
Has this child ever had or been treated for any of the following ? (Please check all that apply)

If yes to any above, please explain in more detail below.

Please list any emotional and/or behavioral issues your child has and any advice you can offer for our teachers to manage these

Medications
Please list all medications and the dosage your child is currently administered regardless of their need to take them during our program. In the event of an emergency, we would share this list with medical care providers.

Medication 1 and dosage

Medication 3 and dosage

Medication 2 and dosage

Medication 4 and dosage

Will your child need to take medicaton or carry an epi-pen and/or inhaler during the program?

Yes

If your child needs to take any medication or carry an epi-pen and/or inhaler, you must complete an Authorization to Administer Medication form. This is available in the confirmation email you received after registering and on the summer watershed discovery page of westportwatershed.org. This must be received at least one week before your child's session begins. All medications must have the pharmacy label on them.

Child Pick-up

* Please be aware that WRWA staff will be checking I.D.s to ensure your child's safety. WRWA will not allow your child to go home with anyone who is not listed as a parent or guardian, who is not listed below, or who is unable to show proof of identity. Please inform people on your list that they must have a license to show our staff. *

Please list all names and phone numbers for the people allowed to pick up your child other than the parents or guardians identified above. You can update this as needed at any time.

Swimming
Please Even though WRWA is not a swimming focused program, we want to understand your child's swimming ability and your comfort with them doing activities at the water's edge or in shallow depths below knee level.

Please tell us your child's swimming ability and their comfort level by the water.

Do you have any concerns with your child doing activities at he water's edge, going in water up to their knees, or swimming if they are at least 10 years old and we have a lifeguard on site?

Sunscreen/Insect Repellant Release

I understand that outdoor exploration is an integral part of WRWA’s Watershed Discovery Programs and that my child will be exposed to risks, including but not limited to, sun, ticks, poison ivy, and insects. I understand that it is my responsibility to apply sunscreen and insect repellant to my child before bringing them to camp each day. I also understand that I am responsible for supplying sunscreen and insect repellant, labeled with my child’s name, so that it can be reapplied by my child or WRWA staff during the day, and that due to possible skin reactions WRWA is not able to provide these for children or allow children to share their supply with others. I understand that some ticks may transmit disease after being attached for over 24 hours, and it is my responsibility to check my child’s body thoroughly every day and to remove any ticks that may become attached. WRWA staff regularly check for ticks and will remove any that are not deeply embedded.

I understand an agree to the terms above in order to protect my child from sun and insect exposure

Yes

I give permission to WRWA to provide hand sanitizer for my child if needed.

Yes

Permission to Participate and Medical Release

Medical Release: I certify that the health history provided above for my child is correct and that my child is healthy and free of problems that could be deleterious to their participation or that of other participants while in the Watershed Discovery Program

I hereby give permission to the WRWA staff to provide routine health care, administer prescribed or over-the-counter medications that I have provided as described, to arrange necessary related transportation for my child in the event of an emergency, and understand there may be charges for which I shall be held responsible.

I give permission to WRWA staff to provide or obtain emergency care. In the event I can not be reached, I give permission to the physician to secure proper treatment or hospitalization, order and administer medications and anesthesia, perform x-rays, special procedures, or surgery if deemed medically necessary by him/her for my child, for which charges I shall be held responsible. I understand this document will be provided to the appropriate physician, dentist, or medical representative in the event of an emergency.

Covid: I understand that WRWA will be mindful of distance when indoors, will have children wash or sanitize their hands regularly, and will not allow sharing of food or supplies that come in contact with a child’s face such as cameras, magnifying lenses, etc. If my child tests positive for Covid I understand they will need to quarantine for five days before being allowed into a summer program, and that I will not receive a refund for missed days.

Insurance: I certify that the named child is covered by health and accident insurance or Medicaid and that the policy information provided is correct.

Risk: I understand there are inherent risks in outdoor programs and that although WRWA takes every measure to ensure safety; it is not possible to foresee every contingency or to eliminate all risk. Program activities include hiking on uneven terrain, collecting animals, playing active games, participating in activities in and near the water and more. I agree on behalf of my child to assume such risks and understand that my child shares the responsibility for their own safety during WRWA programs and activities.

Release/Permission to Participate: I hereby release and forever discharge, agree not to sue, and agree to indemnify and hold harmless the Westport River Watershed Alliance, its agents, employees, interns, and organizational partners, including but not limited to, the Town of Westport, Westport Community Schools and the Westport Land Conservation Trust, from any and all liability, loss, damage, expense, causes of action, suits, claims or judgements for injury to the above-named minor or other persons or their property arising out of, or in connection with, my child’s participation in the Watershed Discovery Programs.

I grant permission for my child to participate in all program activities except those noted below:

I hereby give permission for photographs, images, or videos of my child, and his/her creative materials (poems, drawings, stories etc.) to be used for publicity, public relations, promotional materials and/or newsletters.

Yes

Parent/Guardian Name (Print)

Your Signature

Date

Please correct highlighted fields and resubmit

Thank you for submitting this form

An error occurred. Try again later

Your content has been submitted

Participant Information

Parent or Guardian Name

Second Parent or Guardian Name

Physician & Insurance Information

Emergency Contact
Please list up to three additional contacts that should be reached in case parents or guardians cannot be reached in the event of an emergency

Participant's General Health History
Please list any medical conditions your child has in order to allow our teachers to provide the safest and best possible experience for them

Allergies
i.e. food, medicine, seasonal, environmental, etc.

Medical Information
Has this child ever had or been treated for any of the following ? (Please check all that apply)

Medications
Please list all medications and the dosage your child is currently administered regardless of their need to take them during our program. In the event of an emergency, we would share this list with medical care providers.

Swimming
Please Even though WRWA is not a swimming focused program, we want to understand your child's swimming ability and your comfort with them doing activities at the water's edge or in shallow depths below knee level.

Sunscreen/Insect Repellant Release

Permission to Participate and Medical Release

Get in Touch

Support Us

Participant Information

Parent or Guardian Name

Second Parent or Guardian Name

Physician & Insurance Information

Emergency Contact Please list up to three additional contacts that should be reached in case parents or guardians cannot be reached in the event of an emergency

Participant's General Health History Please list any medical conditions your child has in order to allow our teachers to provide the safest and best possible experience for them

Allergies i.e. food, medicine, seasonal, environmental, etc.

Medical Information Has this child ever had or been treated for any of the following ? (Please check all that apply)

Medications Please list all medications and the dosage your child is currently administered regardless of their need to take them during our program. In the event of an emergency, we would share this list with medical care providers.

Swimming Please Even though WRWA is not a swimming focused program, we want to understand your child's swimming ability and your comfort with them doing activities at the water's edge or in shallow depths below knee level.

Sunscreen/Insect Repellant Release

Permission to Participate and Medical Release

Get in Touch

Support Us

Emergency Contact
Please list up to three additional contacts that should be reached in case parents or guardians cannot be reached in the event of an emergency

Participant's General Health History
Please list any medical conditions your child has in order to allow our teachers to provide the safest and best possible experience for them

Allergies
i.e. food, medicine, seasonal, environmental, etc.

Medical Information
Has this child ever had or been treated for any of the following ? (Please check all that apply)

Medications
Please list all medications and the dosage your child is currently administered regardless of their need to take them during our program. In the event of an emergency, we would share this list with medical care providers.

Swimming
Please Even though WRWA is not a swimming focused program, we want to understand your child's swimming ability and your comfort with them doing activities at the water's edge or in shallow depths below knee level.