(Please print or type)
First Last
P.O. Box or Street
_____________________________
_______________________
______________________
City State Zip
____________________________________________________
th
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Additional Information – please provide the addition information below
Camper Release and Behavior Form
Health Form
Medical Emergency Parental Permission
Publicity/Image/Voice Permission
4-H Club Assumption of Risk and Release of Liability
$150 Registration Fee, discounted if you provide a meal. Scholarships Available.
$50 Registration Fee, if attending 1 day, no overnight.

At Pilgrim Heights, we take our responsibility for the welfare of your child very seriously. We prefer that campers are dropped off and picked up by their legal guardians; however we understand that participants may choose to carpool from all across the state. We need to make sure that the person picking up your child does so with your authorization. Even if you are the person dropping off and picking up your child, we need you to complete this form and send it back to us. We will request a photo ID and match it to the names on the Camper Release Form. Please
plan to bring your Drivers License with you into the lodge for closing ceremonies! We trust that you understand that this precaution is for the safety of the campers. Thank you for your time and consideration.
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Camper: _______________________________________ Session(s) attending: ______________________________
I, ____________________________________________, ( Printed parent's/guardian's name) give permission for my child to be released from camp to the following adults (18 years of age or older):
______________________________________
Name as it appears on driver's license
______________________________________
Relation to Camper
Name as it appears on driver's license
______________________________________
Relation to Camper
Name as it appears on driver's license
______________________________________
Relation to Camper
Parent/guardian signature: ___________________________________ Date:_______________________________
I am picking up the above named child from Pilgrim Heights and assuming full responsibility for him/her.
Name: _____________________________________ Signature: ______________________________________
Name as it appears on driver's license
Released by: _________________________________________ Date: _____________________
Campers are expected to exhibit appropriate behavior at all times. Inappropriate behavior will be discussed with the child when it occurs. Negative behavior effects more than just the camper involved in the misconduct, it affects all those around them. Parents will be notified any time your child is involved in negative behavior, whether initiating or receiving, and your input will be vital in our decisions.
In the event that a camper brings drugs, alcohol, cigarettes, weapons, or explosive devices (including fire crackers) to camp, parents will be contacted immediately to dismiss the camper. Pilgrim Heights also reserves the right to store camper’s personal items that may be inappropriate to their stay. Items will be returned at the end of the week. If a camper is destructive to camp property (breaking windows, graffiti, etc.) the parent will be contacted for appropriate payment and/or dismissal from camp. Pilgrim Heights reserves the right to dismiss any camper due to violence, bullying, or other destructive behavior. Registration fees may or may not be returned at the discretion of the Program Director.
I agree to participate in all scheduled camp activities except where noted by my parent/guardian or by a physician. I also agree to follow established camp behavior policies.
Camper Signature: ___________________________________________________ Date: ________________________
The fees for service will be used to off-set direct expenses and to support the County Extension Program.

PLEASE NOTE - A complete, signed 2016 Health Form is required for ALL participants.
Camper Name (Last, First, Initial)
Address (Street & Number)
Name & Relationship of parent/guardian completing this form
City or Town State Zip Code
Daytime Phone
Date of Birth Age Grade
EMERGENCY CONTACT INFORMATION
Relationship Key: M = Mother F = Father SM = Stepmother
NAME RELATIONSHIP
SF = Stepfather
DAYTIME PHONE
GP = Grandparent
EVENING PHONE
O = Other
CELL PHONE
Are there any legal custodial issues we should be aware of? No Yes If yes, please explain:
INSURANCE INFORMATION (Please attach a copy of your medical insurance card)
Is the participant covered by family medical/hospital insurance? Yes No
If yes, indicate carrier or plan name
Carrier address
Name of insured
Social security number of policy holder or insurance ID number
Group #
Relationship to Participant
CRONIC / RECURRING ILLNESS
Asthma
Bleeding Disorders
Diabetes
Ear Infection
Heart defect / disease
Hypertension
Kidney disease
Mononucleosis
Musculoskeletal disorders
Seizures / Epilepsy
Sinusitis
Tuberculosis
Other (Please Specify)
HEALTH HISTORY – Please check all that apply.
OTHER HEALTH CONDITIONS
OTHER INFORMATION
Has your daughter been taught about menstruation?
Has your daughter begun menstruation?
Specify any special dietary regimen to be followed:
Specify activities to be encouraged:
Specify activities to be restricted:
ADD/ADHD
Bedwetting
Behavioral disturbances
Constipation
Depression
Diarrhea
Emotional disturbances
Fainting
Frequent colds
Frequent headaches
Frequent sore throats
Frequent stomach aches
Yes
Yes
Hearing Impairment
Menstrual cramps
Motion sickness
Night terrors
Nosebleeds
Pediculosis (lice)
Sleepwalking
Wears contacts/glasses
Wears orthodontic device
Others (Specify)
No
No
N/A
N/A
In the last year, has the camper had: an injury/illness requiring medical attention
a surgical operation or fracture
restrictions from participation in P.E. class
an illness lasting longer then 5 days
hospital treatment
exposure to a contagious disease
Is participant currently:
receiving psychological counseling under a physician’s care
restricted from physical activity
taking prescription medication
(Complete reverse side)
taking over the counter medication
(Complete reverse side)
Please explain any items checked above.
Give dates and include any information that would be helpful to camp staff in relation to these health conditions. Add an additional sheet if needed.
List necessary adaptations or limitations:
List all known (medication, food, insect stings, hay fever, etc.)
ALLERGIES
Describe reaction & management of the reaction
**Attach additional pages for more allergies**

The following medications are provided at camp. They will be administered under the designated heath supervisor’s supervision; dosage as appropriate for weight and/or age. We encourage your permission to use them by placing an “X” in the box beside each.
Acetaminophen Antacid Anti-diarrheals Antihistamine
Decongestant Expectorant Diphenhydramine Ibuprofen
DTaP
Pertussis (Whooping Cough)
Td
Measles
Rubella
Hep B
PRESCRIPTION OR OVER-THE-COUNTER MEDICATIONS BROUGHT FROM HOME (Please complete below)
MEDICATION CONDITION TREATED DOSAGE TIME OF DAY TAKEN WITH FOOD?
B-fast
B-fast
Dinner
Lunch
Dinner
Bedtime As needed Other
Lunch
Bedtime As needed Other
B-fast
Dinner
Lunch
Bedtime As needed Other
RECORD OF IMMUNIZATION
Date of Last Immunization
Diptheria
Tetanus (within last 10 yrs)
Oral polio / IPV
Mumps
Hib
Tuberculin Test Yr last given
Date of Last Immunization
Result
HEALTH STATEMENT
This health record, including the allergy and medicine information on this form is complete and accurate. My camper has my permission to engage in all prescribed activities, including strenuous activities such as hiking, swimming, climbing hills, except as noted by me and the examining MD/DO/ARNP.
I give my permission for the camp staff to provide first-aid and to obtain in-camp or out-of-camp healthcare treatment for my camper should the need arise. In case of emergency, healthcare treatment beginning with first-aid provided by designated camp staff, EMT and local clinic/hospital staff will be given under the supervision the camp staff. I understand there is also a HealthCare Waiver available, for adult (18+ yrs.) staff and adult campers to sign if desired. Emergency contacts on the opposite side of this form will be contacted as soon as possible.
HEALTH INFORMATION PRIVACY STATEMENT
This health form is for health care concerns at Pilgrim Heights camp sessions only. All records will be handled by staff / volunteers whose job includes processing or using this information for the benefit of the participant. All medical records will be held in limited access by the Director/Dean at each camp. Minimal necessary information will be shared with other staff / volunteers in order to provide adequate participant safety and health care. The health form will be retained by Pilgrim Heights Camp and Retreat Center until it is destroyed. All forms / records with noted treatment will be retained for seven years past the age of maturity of the participant. I have read the above procedures for handling the heath form and agree to the release of any records necessary for treatment, referral, billing, or insurance purposes.
SIGNATURE OF PARENT OR GUARDIAN DATE
**************************************** PHYSICAL EXAMINATION ****************************************
NOTE TO PHYSICIAN: Must be within the last 2 years.
Required for any individual participant attending program. However, adult program participants do not need to complete the following section.
DATE OF HEALTH EXAMINATION:
Nose Throat
Teeth
Lungs
Genitalia
Heart
Abdomen
Hernia
Skin Musculoskeletal
General Physical / Mental / Psychological status
Urinalysis* HGB*
Other Notes:
Physician’s comments and/or recommendations.
Give details or indicate management or significant illnesses.
*Not required for every health exam.
Height Weight
Appearance / Nutrition
W/OUT GLASSES
EYES R 20/ L 20/
B.P.
W/GLASSES
R 20/ L 20/
EARS Hearing Right
Measles
Hearing Left
Which of the following, if any, has the patient had?
Chicken Pox Mumps
Hepatitis German Measles
This person is in satisfactory condition and may engage in all usual activities, except as noted.
Name of Licensed MD/DO or ARNP :
Signature of Licensed MD/DO or ARNP :
Address

Phone Date
TO BE READ AND SIGNED BY PARENT OR GUARDIAN
I understand that my child must be healthy and reasonably fit in order to safely participate in 4-H recreation activities and that I will inform the program leader(s) of any medication, ailment, condition, or injury that may affect his/her ability to participate safely.
MEDICAL EMERGENCY PARENTAL PERMISSION*
The health history for my child is correct and complete to my knowledge. If an injury or other medical condition occurs or arises, I hereby give permission to the ISU Extension staff or volunteer to provide routine first aid and seek emergency treatment including x-rays or routine tests. I agree to the release of any record necessary for treatment, referral, billing or insurance purposes. I understand that I am financially responsible for charges to the attending physicians or health care unit (other than those covered by an ISU Extension accident insurance plan). In the event of an emergency where I cannot decide for my child, I give permission to the physician/hospital selected by the ISU Extension staff or volunteer to secure and administer treatment for my child, including hospitalization. (*If you cannot sign this section of the form for any reason, contact the County Extension Director regarding a legal waiver in order to attend and participate.)
_________initial __________date
PUBLICITY/IMAGE/VOICE PERMISSION
The Iowa State University Extension 4-H Program normally takes photographs, video, and/or tape recording of our programs. During activities, a photograph or video/audio recording may be taken of you or your child. Unless you request otherwise, your initial below will be considered permission for Iowa State University and the 4-H Program to photograph, film, audio/video tape, record and/or televise your image and/or voice or the image and/or voice of your child for use in any publications or promotional materials, in any medium now known or developed in the future without any restrictions. If you object to ISU using you or your child’s image or voice in this manner, please notify the 4-H program leader.
_________initial __________date
4-H CLUB ASSUMPTION OF RISK AND RELEASE OF LIABILITY (Please read carefully.)
I give permission for to participate in the 4-H program. I understand that 4-H club project activities/events may involve certain risks of physical activity and possible injury and that Iowa State University and its 4-H program will provide each participant with reasonable care, but that ISU cannot guarantee that my child will remain free of injury. In addition, some 4-H projects including but not limited to: shooting sports, horse or livestock projects, water activities, and other sporting activities have a higher degree of risk. I nonetheless wish to have my child participate as an Iowa 4-H club member in the 4-H club program and ASSUME the RISK of participating. I agree to RELEASE from
LIABILITY, INDEMNIFY and HOLD HARMLESS the State of Iowa, the Board of Regents of the State of Iowa, ISU and
ISU Extension and their officers, employees and agents (hereinafter the RELEASEES) from any and all claim and/or cause of action arising out of and related to any injury, loss, penalties, damage, settlement, costs or other expenses or liabilities that occur as a result of my child’s participation in the 4-H program. This release, however, is not intended to release the above-mentioned RELEASEES from liability arising out of their sole negligence.
Parent or Guardian Signature Date
(Must be signed by the parent or guardian if the participant is under 18 years old)
. . . and justice for all
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.)
Many materials can be made available in alternative formats for ADA clients. To file a complaint of discrimination, write USDA, Office of Civil Rights,
Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 20250-9410 or call 202-720-5964.
Issued in furtherance of Cooperative Extension work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture.
Cathann Kress, Director, Cooperative Extension Service, Iowa State University of Science and Technology, Ames, Iowa.