The purpose of this health form is to assist Pine Cove Health Care Staff in identifying appropriate care. The information in this form will only be available to staff who will be working with your camper. This health form is required for camp attendance and must be completed by the camper’s parent/guardian. Health forms from last year are not valid for this year.
Backup Emergency Contact
REQUIRED – must be someone who does not live with the camper. Please provide contact information for other people who know your camper and with whom we can consult if we cannot reach you. We assume you have spoken with these individuals and that they are willing to assist should the need arise.
Pine Cove offers limited insurance as part of your registration fee. Coverage is a maximum $2500 for accidental, $750 for illness, and $2500 total benefit.
We will make every attempt to communicate concerns regarding peanut allergies but do not guarantee zero exposure. We are not peanut free.
Please list ALL prescription medication, over-the-counter and non-prescription drugs taken routinely. Fill in the blanks completely. Bring enough medication to last all week. Empty bottles will be returned to your camper. All drugs must remain in the original container. All prescription medications must be in a pharmacy-labeled container with the camper’s name on it. Loose pills and samples will not be accepted.
The information given in this form is complete and accurate to the best of my knowledge. I hereby give my permission for my camper to participate in all camp activities.
1. I hereby give my permission for Pine Cove to use or disclose Protected Health Information (PHI) to necessary staff and any volunteer or paid health care professional or facility for diagnosis, treatment, health care needs, emergency medical care or coverage information for my camper as described on the enclosed Notice of Privacy Practices from Pine Cove, Inc.
2. I hereby give my permission to licensed Pine Cove medical/nursing staff, volunteer physicians and volunteer licensed medical/nursing staff to administer prescribed medication, provide health care, and seek emergency medical care. I hereby give my permission to Pine Cove to provide or seek transportation to medical facilities for my camper. In case of emergency where I can’t be contacted, I hereby give permission to the physician selected by Pine Cove to secure and administer proper treatment, hospitalize, order injections, order anesthesia and/or surgery for my camper. Note: Volunteer licensed medical/nursing staff are utilized at our Camp in the City locations only. We utilize licensed Pine Cove medical/nursing staff and volunteer physicians at all other locations.
3. I HEREBY GIVE MY PERMISSION FOR LICENSED PINE COVE MEDICAL/NURSING STAFF AND VOLUNTEER LICENSED MEDICAL/NURSING STAFF TO ADMINISTER OVER-THE-COUNTER MEDICATIONS TO MY CAMPER AS NEEDED.
4. I understand that the Nurse Manager and/or the Camp Director reserves the right to send home a camper whose medical condition becomes unmanageable and/or places the camper or Pine Cove at risk in the Camp environment.
5. Camping standards DO require that each camper have a physical exam by a Physician, Nurse Practitioner, or Physician’s Assistant within 24 months (2 years) of attending camp (e.g., campers who will attend August 2019 must have a physical exam between September 2017 and August 2019). I, the parent/guardian of this camper hereby certify that he/she has met the requirement of a physical exam conducted by a Physician, Nurse Practitioner, or Physician’s Assistant within 24 months (2 years) of attending summer camp in 2019 OR will complete this requirement prior to his/her attendance at Pine Cove. I understand this stipulation is a requirement of Pine Cove and is not optional. My camper has had a physical exam within 24 months of his/her attendance at Pine Cove OR will have one prior to participation for the summer of 2019. THIS PHYSICAL EXAM IS REQUIRED FOR ATTENDANCE.
6. I agree to make Pine Cove aware of all known medical issues regarding my camper’s health and will update this form with additional issues that may occur between now and the start of camp.
7. I agree and understand that Pine Cove’s Supplemental Camper Insurance is a limited offering. The maximum amount is $2,500 for accidents and $750 for illness. My insurance information will be provided for amounts that exceed this offering.
We at Pine Cove, Inc. (“Pine Cove”) want to inform you of our safety precautions at camp. We feel that we have hired competent and knowledgeable staff. Nonetheless, your camper will be required by our staff to wear safety equipment for any activities requiring protective gear. Even with safety equipment, we at Pine Cove want you to realize that any outdoor camping and recreational activity has inherent dangers that no amount of care, caution, instruction or expertise can eliminate.
• I hereby affirm that I have been advised of and understand the risks of camping and recreational activities at Pine Cove and that such activities involve dangers and risks and I accept those dangers and risks knowingly and willingly for my camper.
• I understand that pictures and videos, and audio recordings are taken at camp. I hereby give permission for the use of such pictures, videos, and audio recordings of my camper for the promotion of Pine Cove.
• In addition, I give permission for my camper to be transported in vehicles for camp approved transportation and activities at Pine Cove and other locations.
• I understand that the terms herein are contractual and binding and not mere recitals. In signing this document, I hereby certify that I give permission for my camper to
participate in the camping and recreational program of Pine Cove.
• I understand that the terms herein and my agreement to them applies for all of the calendar year of 2019 and all events occurring in 2019.
• I have signed this document as my own free act and in consideration of the agreement by Pine Cove to accept my camper for 2019.
• BY EXECUTION OF THIS DOCUMENT, I KNOWINGLY AND WILLINGLY RELEASE PINE COVE, THE STAFF, THE BOARD OF DIRECTORS, AND ALL OTHERS
ACTING FOR OR ON BEHALF OF PINE COVE FROM ALL LIABILITY WHATSOEVER, FOR PERSONAL INJURY, OR INJURIES TO PROPERTY, REAL OR PERSONAL,
CAUSED BY, OR ARISING OUT OF CAMPING AND OTHER ACTIVITIES SPONSORED BY PINE COVE.
We want to get to know your camper!
Choose the word that best describes
your child from each group:
Each camp attendee must participate in one 4 hour work day (12 - 4pm).
Confirmation: We have received your application. Please expect further communications from Mercy Street Mentor Coordinators. Thank you!