Kent Mountain Adventure Center, Inc.

                                                                 P.O. Box 835

                                                           Estes Park, CO  80517

                                                                (970) 586-5990

                                                        Participant Medical Form

To be filled out by parent/legal guardian:  Please note:  Physician signature is required on page 2

COMPLETED FORM IS REQUIRED

Participant Name: ___________________________________   Age: ____   Date of birth: ______/_____/_____

Address/P.O. Box: _____________________________________________________________________________

City: _____________________________________________________   State: ___________   ZIP: ____________

Name of Course: _______________________________________________________________________________

M _____    F _____     Height:  ___________  Weight: _____________  Last physical exam: _____/_____/_____

Emergency Contact Name: Parent/Guardian: _______________________________________________________

Day phone: (________)______________________________   Night phone: (________)_____________________

If parents/guardian cannot be contacted, please contact (list two individuals):

1.  Name: _______________________________________              2.  Name: __________________________________

Relationship to participant: ________________________     Relationship to participant: ___________________

Home phone: (________)__________________________                  Home phone: (________)______________________

Business phone: (________)_______________________                    Business phone: (________)____________________

HEALTH HISTORY

List any chemical or drug allergies (penicillin, sulpha, iodine, etc.): ____________________________________________

______________________________________________________________________________________________________

List any allergies: food (nuts, fish, peanut butter, dairy, etc.), insects (bee stings, etc.), hayfever (pollen, mold, etc.): ______________________________________________________________________________________________________

______________________________________________________________________________________________________

Has participant ever been stung by a bee/wasp:    Yes  q     No  q

Does the participant have a history of any of the following:  Please check all that apply:

qAsthma             qrespiratory disorder         qfainting          qdizziness           qdiabetes           qhypertension

qSeizure disorder            qheadaches        qeating disorder              qsleep walking                 qbed wetting

qDepression        qhomesickness                  qheart disease/defect      qnose bleeds                   

Continued (over)

Does the participant have any other pre-existing medical conditions?  Please list:_________________________________

______________________________________________________________________________________________________

Special diet?: __________________________________________________________________________________________

Past history of injuries (include dates): ________________________________________________________________

__________________________________________________________________________________________________

I give permission to Kent Mountain Adventure Center to give the following if deemed necessary to relieve minor pain and discomfort: 

Parent/legal guardian signature:________________________________________________________________________

Tylenol                                             Yes q  No q                      Ibuprofen                                        Yes q  No q

Imodium for diarrhea                     Yes q  No q                      ExLax for constipation                    Yes q  No q

Decongestant                                   Yes q  No q                      Antihistamine(Benadryl)                  Yes q  No q

Antacid for indigestion                    Yes q  No q                      Throat lozenges                               Yes q  No q

Sunblock or sunscreen                    yes q  No q                      Hydrocortisone Cream                    yes q  No  q

Claritin(loratadine)                         yes q  No q

Participant's Doctor: _______________________________________________  Phone: (_______)________________

Doctor's address: __________________________________________________________________________________

I have prescribed the following medications to be administered.  I have examined the participant named on this form and found him/her to be in satisfactory physical condition and capable of active participation in an outdoor adventure based program:

Physiciansignature:_______________________________________________________________________________

Name of med.: ______________________________           Name of med.: ____________________________________

Dosage: __________________________________              Dosage: __________________________________________

Times given: ______________________________              Times given: ______________________________________

Date medication started: ____________________   Date medication started: ____________________________

Reason for medication: _____________________   Reason for medication: _____________________________

Name of med.: ______________________________           Name of med.: ____________________________________

Dosage: __________________________________              Dosage: __________________________________________

Times given: ______________________________              Times given: ______________________________________

Date medication started: ____________________   Date medication started: ____________________________

Reason for medication: _____________________   Reason for medication: _____________________________

Continued (over)

Self-Carry medication release for Sun block, Rescue inhalers, Epi-pens and insulin pumps

I request that the above named participant be permitted to carry one or all of the following:

Please check all that apply: (must be prescribed above per physician orders):

qSun block                           qEpi-pen                    qAlbuterol Inhaler                         qInsulin Pump Pens

qOther____________________________________________________________________________________________

The above noted “self-carry” items/medications are permitted for the indicated participant at all times.  He/she has been instructed by the physician and parents and acknowledges the proper understanding of the purpose, frequency, and appropriate method of use of these items. 

Parent/legal guardian signature:_______________________________________________________________________

Additional comments (Please describe on page 4):

IMMUNIZATION RECORD

Attach Colorado Certificate of Immunization or complete the following:

In case of an emergency, every effort will be made to contact me.  In the event I cannot be reached, I hereby give my permission to the physician selected to hospitalize and secure proper treatment (including emergency care) for my child.

Signature of parent/legal guardian: ___________________________________________  Date: _____________

Signature of participant: _____________________________________________________  Date: ____________

Medical Health Insurance: Company: ______________________________________________________________

Address: _____________________________________________________________________________________

Policy #: ___________________________  Group #: ____________________  Phone: (_______)______________

Continued (over)

PLEASE NOTE THE FOLLOWING:  ALL PARTICIPANTS ARE REQUIRED TO HAVE A PHYSICAL EXAM BY A PHYSICIAN OR NURSE PRACTITIONER WITHIN ONE YEAR PRIOR TO PARTICIPATION. 

If there are any changes in the participant's medical status between now and the course departure, please contact KMAC with the new information as soon as possible (970) 586-5990.

Kent Mountain Adventure Center is licensed by the Colorado Department of Human Services to conduct “trip” camps for children.  In accordance with this license, KMAC is required by the Division of Child Care to report suspected child abuse.  Any person who suspects child abuse should contact:

Larimer County Department of Human Services

Phone:  (970) 498-6300

Any person or entity that wishes to file a complaint against Kent Mountain Adventure Center for suspected licensing violations should contact the Division of Child Care at the address and phone number below. 

Colorado Department of Human Services

Division of Child Care

1575 Sherman Street, First Floor

Denver, CO  80203-1714

Phone:  (303) 866-3755