Fair Winds Farm Registration, Health History and Emergency Contact Form INSTRUCTIONS:Please provide detailed information by simply typing your anwsers next to the questions. When you finish please press the submit button to send your information. Student Information Camp Date student is attending: Name: Age: Sex: Phone Numbers: Email: Address: City and State: _____________________________________________________________________________________________ Parent Guardian Information (1)Name: Phone Numbers: Email: (2)Name: Phone Number: Email: _____________________________________________________________________________________________ Emergency Contact Information Who do we contact in case of an emergency? Name: Phone Numbers: If the above person can not be reached, who should we notified? Name: Phone Numbers: _____________________________________________________________________________________ Student Health and Medical History Does the student have any known Allergies? Does the allergy cause: Intolerance or Anaphylaxis? Details: Has the student ever experienced any of the following? (please put a (X) next to the ones that apply) Asthma Bleeding Disorders Attention Disorders Eating Disorders Wears Contacts/Glasses Diabetes Fainting Spells High Blood Pressure Other: Please describe any condition or need that you checked: Is the student experiening any current health promblems, under medical care, receiving mental or behavioral services or currently taking any medications? If YES, please explain: Has the student undergone surery or experienced any injury, illness, allergy or change in health status any time during the last year? If YES, please explain? What else should we know about the health of your child? ___________________________________________________________________________________________ Immunization History Are the student's immunizations up to date? ___________________________________________________________________________________________ Please sign below that all the information above is correct then press submit button: (Typing your name is your signature) Students Name: Date: Students Signature: Parent/Guardian Name: Date: Parent/Guardian Signature:
