Camp PAGEA1 - The Fresh Air Fund / Home Child Application... · If we are unable to reach you, we will call the contacts in the order listed below. Emergency contacts must be 18

If we are unable to reach you, we will call the contacts in the order listed below. Emergency contacts

must be 18 years or older and must be authorized to pick up your child. Please call The Fresh Air Fund to authorize an adult

not listed on this page to pick up your child.

Program: Friendly Towns Camp Career Awareness Has this child participated in a Fresh Air Fund program before? Yes No

Child’s last name:

Child’s first name: M.I.:

Date of birth: Age: Gender: Male Female

Child’s address: Apt #:

City: Borough: Zip:

School: _______________________________________ School borough: ___________________ Current grade:

Contact name (not a parent or guardian listed above)

Relationship Phone numbers (e.g. cell, home, work)

_________________________________________ _______________ _____-_____-_______ / _____-_____-_______ 1

_________________________________________ _______________ _____-_____-_______ / _____-_____-_______ 2

_________________________________________ _______________ _____-_____-_______ / _____-_____-_______ 3

Parent / Guardian 1:

Home : Cell :

Work : Email: _____________________________________________________

* Relationship to child: _______________________________ Parent/Legal Guardian Currently living with child

Parent / Guardian 2:

Home : Cell :

Work : Email: _____________________________________________________

* Relationship to child: _______________________________ Parent/Legal Guardian Currently living with child

* Please note: If you are the Legal Guardian, please provide a copy of court–approved guardianship papers.

Please write FIRST then LAST NAME. Individuals listed below must be authorized to pick up the child.

*PAGEA1*

For internal use only

DATE RECEIVED BY FAF: DATE ENTERED: BY:

M M D D Y Y Y Y

Please do not cover barcode

On the phone, I prefer to speak:

English Spanish Mandarin Cantonese Korean Other (specify)

It is best to contact me during the following time period (Check all that apply): 8am-12pm 12pm-4pm 4pm-8pm

Partnering Agency/Source: _______________________________ Completed by: ___________________________ Date: __________ Partnering Agency Staff

Please use BLUE or BLACK ink.

Is this child in Foster Care? Yes No If Yes, Page 2 is required and must be completed by Foster Care Agency

Must be Completed by Foster Care Agency

Foster Parent Name:

Home : Work :

Cell : Email: _____________________________________________

*PAGEA13*Please do not cover barcode

Child’s last name: Child’s first name: MI:

Agency Name:

Case Worker Name: Supervisor Name:

Work : Work :

Cell : Cell :

Email: _____________________________________________ Email: _____________________________________________

Is this applicant currently in foster care? Yes No

YES - Complete this form NO – Go to Page 3.

Please list the individuals authorized to pick up this child (if different than those on Page 1):

Contact name Relationship Phone numbers (e.g. cell, home, work)

_________________________________________ _______________ _____-_____-_______ / _____-_____-_______ 1

_________________________________________ _______________ _____-_____-_______ / _____-_____-_______ 2

_________________________________________ _______________ _____-_____-_______ / _____-_____-_______ 3

The biological parent can: Communicate with The Fund’s staff or volunteers and edit this application? Yes No

Get information about the trip dates and location? Yes No

Communicate with the child during the scheduled trip? Yes No

Biological Parent Name (If applicable):

Home : Work :

Cell : Email: _____________________________________________

Signature: Date: ___/___/____

Print Name:

Title:

MM DD YYYY

This child has been in foster care since: ___/___/___

This child has been in the current foster home since: ___/___/___ MM DD YYYY

MM DD YYYY

List all known allergies and describe reaction and authorized treatment of the reaction in each case:

A copy of the official immunization record must be attached

TB Mantoux Test

Date of test: ____ / ____ / ____ Result: Negative Positive MM DD YYYY

If positive, chest x-ray result: ___________

Does this child take TB meds? No Yes

If YES, please list medication:

Since: ___/___/___ & Regimen: 3 mo. 6 mo. 9 mo. MM DD YYYY

This child is no longer contagious and may participate No Yes

in a residential community

Has this child had any of the following?

Sickle Cell Lyme Disease

Diabetes Seizure Disorder

Heart Disease Rheumatic fever

Measles Chicken pox

German measles Mumps

Hepatitis Tuberculosis

Other Communicable Diseases* (indicate below)

Congenital or Acquired Heart Disorder

Speech, Hearing, or Visual Impairment

*

Child’s last name: ___________________________________ Child’s first name: _____________________________ MI:_____

Child’s date of birth: _____/_____/_____ Gender: Male Female

Does this child have asthma/RAD? No Yes

If Yes: Intermittent Mild Persistent Moderate Persistent Severe Persistent

Is the child prescribed asthma medication? No Yes

If Yes, please list medication(s): Albuterol Ventolin Qvar Flovent Singulair other:

Does child have an Asthma Treatment Plan? No Yes If Yes, please provide a copy

Child: Must travel with inhaler/other asthma medications

May travel without inhaler/other asthma medications

Does not require inhaler/other asthma medications

Doctor’s full name: Doctor’s telephone : ______-______-_________

Doctor’s address: Doctor’s fax : ______-______-_________

Has this child been diagnosed with ADD or ADHD? No Yes

If Yes, is medication prescribed? No Yes

If Yes, please list medication: Concerta ___mg Adderall ____mg Ritalin ____mg Other: ___________ ____ mg

REQUIRED: Must be Completed by Doctor/Qualified Medical Personnel *PAGEA2*Please do not cover barcode

Allergen Reaction/Symptoms Treatment/Medication/Dosage

Food allergy: (e.g. peanuts, shellfish, berries etc.) Epi Pen required

Environmental allergy: (e.g. pollen, dander etc.) Epi Pen required

Medication allergy: (e.g. Penicillin, etc.) Epi Pen required

Date of last asthma-related emergency room visit:

____ / ____ / ____ MM DD YYYY

Child: Must travel with Epi-pen May travel without Epi-pen Does not require an Epi-pen

MM DD YYYY



Drug Name Indications Remarks

Tylenol (or generic acetaminophen) Pain or fever

Ibuprofen Pain or fever

Robitussin/Jr. (or generic) Cough

Chloraseptic (or generic) Sore throat

Children’s Mylanta (or generic antacid) Upset stomach

Milk of Magnesia (or generic laxative) Constipation

Mucinex/Jr. (or generic) Congestion

Visine (or generic) Eye redness / irritation

Sudafed (or generic) Nasal congestion / Eustachian tube congestion

Claritin (or generic) Nasal congestion / Seasonal allergy symptoms

Benadryl (or generic diphenhydramine) Allergic reactions (hives, insect bites)

Antibiotic Ointment Superficial cuts / abrasions

Hydrocortisone Cream Allergic reactions (contact dermatitis, insect bites)

Calamine Lotion (or generic) Allergic reactions (hives, insect bites)

I certify that the medical history of this child is correct, and that he or she has medical clearance to engage in all activities, except for those noted on this form. In addition I authorize that (unless otherwise noted in “Remarks” above) medications listed under Other Authorized Medications section can be dispensed at the discretion of medical personnel at camp and/or a host parent in Friendly Town per dosage, schedule and route indicated on the label.

Doctor’s Signature: _______________________________ Date of Examination: _____/_____/_____

REQUIRED. Must be Completed by Doctor/Qualified Medical Personnel

This child does not take medications on a routine basis

This child does take medications on a routine basis as follows:

Please list ALL medications currently and routinely taken (including prescription, non-prescription or over-the-counter).

Medication name Route Dosage Frequency Diagnosis/Comments

Weight: ______ Height: _______ BP: _________

This child is able to participate in a physically active program, including swimming Yes No

Does this child have any restrictions, physical limitations, developmental or learning delays?

None (within normal limits)

Yes - please fill out the rest of this section: Physical Cognitive Communication/Language

Social/Emotional Adaptive/Self-Help Behavioral Other

Please explain:__________________________________________________________________________________________

MM DD YYYY

The following medications are available in the camp infirmary and will be dis-pensed at the discretion of medical personnel, unless otherwise noted by the child’s healthcare provider. As this child’s healthcare provider you authorize that (unless otherwise noted in “Remarks”) the medications listed below can be dispensed at the discretion of medical personnel at camp and/or a host parent in Friendly Town per dosage, schedule and route indicated on the

Date of Exam must be after June 1, 2016

REQUIRED: Must be Completed by Doctor/Qualified Medical Personnel



Must be Completed & Signed by Parent/Legal Guardian *PAGEA14*Please do not cover barcode

New York State Public Health Law requires that a parent or guardian of

a child who attends an overnight children’s camp for seven (7) or more

consecutive nights, complete and return the following form to the camp.

Check one box and sign below.

My child has had the meningococcal conjugate vaccine -MCV4 (ex. Menactra or Menveo).

Date received: _______/_______/_______ MM DD YYYY

[Note: The Centers for Disease Control and Prevention recommends two doses of MCV4 for all adolescents 11 through 18

years of age: the first dose at 11 or 12 years of age, with a booster dose at age 16. Adolescents in this age group with HIV

infection should get three doses: 2 doses 2 months apart at 11 and 12, plus a booster at age 16.

If the first dose (or series) is given between 13 and 15 years of age, the booster should be given between 16 and 18. If the

first dose (or series) is given after the 16th birthday, the booster is not needed.]

I have read, or have had explained to me, the information about meningococcal meningitis disease

and vaccination. I understand the risks of not receiving the vaccination, and have decided that my

child will not obtain immunization against meningococcal meningitis disease.

Signature: Date: _______/_______/_______ MM DD YYYY

Print Name:

Email Address:

Mailing Address:

City: State: Zip:

Meningococcal Meningitis Vaccination Response Form

MM DD YYYY



Must be Completed by Parent/Legal Guardian *PAGEA15*Please do not cover barcode

Please submit a clear photocopy (front and back) of your

child’s health insurance card

My child has private health insurance (e.g. through my employment or the open market)

My child has health insurance through NYS Medicaid

My child does not have health insurance

Policy Holder Name:

Insurance Provider:

Group Number: Policy Number:

Does this policy include dental coverage? No Yes

MM DD YYYY

*PAGEA4*

Has/does your child: NO YES

1. Had a recent injury, illness or infectious disease?

2. Had a chronic or recurring illness/condition?

3. Ever been hospitalized?

4. Ever had surgery?

5. Had frequent headaches?

6. Ever had a head injury?

7. Ever been knocked unconscious?

8. Ever had frequent ear infections?

NO YES

9. Ever been diagnosed with a heart murmur?

10. Ever had seizures?

11. Had skin problems (e.g. itching, acne, eczema)?

12. Been treated for head lice in last six months?

13. Ever had problems with diarrhea/constipation?

14. Ever had an eating disorder?

15. Wear glasses, contacts or protective eye wear?

16. If female, begun to menstruate?

If not, does she know about the menstrual cycle?

Please explain any ‘yes’ answers. Include the question number and the most recent occurrence.

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Must be Completed by Parent/Legal Guardian

Does your child receive any type of counseling, therapy or treatment in or out of school?

(Please include services for ADD/ADHD, mental, emotional, behavioral, social and other disorders)

No Yes If yes, The Fresh Air Fund’s Evaluation Form is required. Please call 1-800-367-0003.

Please provide counselor, therapist, social worker contact information:

Name:

Does your child receive any special education and/or supportive services (IEP) in school?

No Yes If yes, The Fresh Air Fund’s Evaluation Form is required. Please call 1-800-367-0003.

Type of special education and/or services:__________________________________________________________________

Language spoken in home:

English Spanish Mandarin Cantonese Korean

French Creole French Arabic Bengali Other:________________________

Race/Ethnicity:

African American/Black African American Indian or Alaskan Native Asian South Asian

Hispanic/Latino White Other:________________________________ No Response

Country/Countries of Origin: _____________________________________

Is your child in English Language Learner (ELL) classes in school? No Yes If yes, what native language(s)? ___________

Total # of people living in the household: # of school-aged children (7-12) in the household: __________

Please list the names and ages of any other children in your home who are applying to The Fresh Air Fund’s 2017 programs:

__________________________ __________________________ __________________________ __________________________

Phone :



These questions will assist our host families and staff in caring for your child and in creating a positive experience during

their time with us. Please provide as much information as possible. Check all boxes that apply.

Does your child have any dietary restrictions (e.g. vegetarian, no pork, lactose intolerant, gluten-free)? No Yes

If Yes, please explain: _______________________________________________________________________________________

Does your child have a Special Dietary Plan? No Yes If Yes, please provide a copy

If Yes, are these restrictions due to: Allergies/Medical Condition(s) Religious Beliefs Personal Preferences

Has your child been adjusting to any of the following changes in the last year?

New school New brother/sister Loss of a close friend Divorce/separation of parents Death of: ____________

Other changes: __________________________________________________________________________________________

Does your child know how to swim? No Yes

Does your child have a fear of being in the water? No Yes Explain ________________________________________

Is your child afraid of or uncomfortable around animals? No Yes Explain ____________________________________

Has your child been away from home before? No Yes Where? ___________________________________________

Does your child wet his/her bed? No Yes How often? ___________________________________________________

What are your child’s favorite activities and/or interests? (Check all that apply)

What are your child’s favorite foods? What are your child’s least favorite foods?

Does your child have a favorite nickname? No Yes ____________________________________________________

Tell us more about your child: (e.g. How does your child respond to new people or environments? How might your child respond if s/he does not want to do a planned activity? Is your child outgoing? Is your child the oldest/youngest sibling? etc. )

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

My child is generally (check all that apply): Active Angry Athletic Bright Cheerful

Curious Dependent Easily Frustrated Easy Going Fearful Happy Immature

Independent Irritable Joyful Mature Outgoing Quiet Sad Shy Talkative

Sports

Swimming/Water Activities

Video/Computer Games

Watching TV/Movies

Other (Please Explain)

Reading

Bicycling

Hiking

Playing Outdoors

Amusement Parks/Rides

Arts & Crafts

Gardening

Cooking & Baking

Please do not cover barcode *PAGEA5*



Part 1. Children enrolled in Camp or Summer Programs.

Names (First, Middle Initial, Last) SNAP, TANF or FDPIR Case # (if any) Foster Child*

*Foster children are eligible for free and reduced-price meals regardless of household income. Please ensure that you have checked the Foster Child box for any foster children listed above. Complete Part 2 if you are applying for other children in your household and

you did not enter a SNAP, TANF or FDPIR case number in Part 1 above. If not, skip to Part 3.

Part 2. Total Household Gross Income. You must tell us how much you earn and how often it is received.

Name(s) Gross income and how often it is received

(List everyone in the household,

including children)

1. Earnings From

Work before

deductions

2. Welfare, child

support, alimony

3. Pensions, Social

Security, Ret., SSI,

VA benefits

4. All Other

Income Check if NO

Income (Example) Jane Smith Ex.: $26,000.00/annually OR $2,166.67/monthly OR $1,000.00/bi-weekly OR $500.00/weekly

$______/_________ $______/________ $______/________ $______/________

$______/_________ $______/________ $______/________ $______/________

$______/_________ $______/________ $______/________ $______/________

$______/_________ $______/________ $______/________ $______/________

$______/_________ $______/________ $______/________ $______/________

$______/_________ $______/________ $______/________ $______/________

$______/_________ $______/________ $______/________ $______/________

$______/_________ $______/________ $______/________ $______/________

Part 3. Signature and Social Security Number (Adult must sign).

An adult household member must sign the application. If Part 2 is completed, the adult signing the form also must list the last four digits of his or her Social Security Number or mark the "I do not have a Social Security Number" box. (See Statement on the back of this page. ) I certify that all information on this application is true and that all income is reported. I understand that this information is being given for the receipt of Federal funds. I understand that SFSP officials may verify [check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted.

Sign here:_____________________________________________ Print name:___________________________________________

Date:____________________ Phone Number:

Address:

City: State: Zip Code:

Last four digits of Social Security Number: * * * - * * - I do not have a Social Security Number

Part 4. Children’s ethnic and racial identities (Optional).

Choose one ethnicity:

Hispanic/Latino Hispanic/Latino

Choose one or more [regardless of ethnicity): Asian can Indian or Alaska Native

DO NOT WRITE BELOW THIS PART. IT IS FOR OFFICIAL USE ONLY.

Total Income: ___________ Per: Week, 2 Weeks, A Month, size:

Categorical Eligibility Date Withdrawn: ________ Eligibility: Free Reduced Denied

Reason:

Determining Official’s Signature: _ Date:

Confirming Official’s Signature: Date:

Verifying Official’s Signature: Date:

*PAGEN6*Please do not cover

barcode

Annual Income Conversion: Weekly x 52 Every 2 Weeks x 26 Twice A Month x 24 Monthly x 12

Must be completed

& signed

If receiving SNAP, TANF or FDPIR, provide child’s name and Case # in Part 1. Skip Part 2. Go to Part 3. If child is in foster care, provide child’s name and check box in Part 1. Skip Part 2. Go to Part 3.

If you have income, provide the names of all people living in your household and their income then go to Part 3.

Income Eligibility Form for the Summer Food Service Program

Please complete the form using the instructions below. Sign the form and return it with your application to The Fresh Air

Fund. If you need help completing the form, please contact us at 1-800-367-0003.

IF YOUR HOUSEHOLD GETS SNAP, TANF or FDPIR, FOLLOW THESE INSTRUCTIONS

Part 1: List each participant’s name and a SNAP, TANF or FDPIR case number

Part 3: Sign the form. The last four digits of a Social Security Number are not necessary.

Part 4: Answer this question if you choose to.

IF YOU ARE APPLYING FOR A , FOLLOW THESE INSTRUCTIONS

Part 1: Enter the name of each foster child. Check the box indicating the child is a foster child.

Part 3: Sign the form. The last four digits of a Social Security Number are not necessary.


ALL OTHER HOUSEHOLDS, INCLUDING WIC HOUSEHOLDS, FOLLOW THESE INSTRUCTIONS

Part 1: List each participant’s name.

Part 2: Follow these instructions to report total household income from this month or last month.

Box 1 – Name: List all household members with income.

Box 2 – Gross Income and How Often It Is Received: For each household member, list each type of income received

for the month. You must tell us how often the money is received—weekly, every other week, twice a month or monthly.

o For section 1 in box 2, be sure to list the gross income, not the take-home pay. Gross income is the amount

earned before taxes and other deductions. You should be able to find it on your pay stub or ask your employer.

For ONLY the self-employed, report income after expenses. This is for your business, farm, or rental

property.

o For section 2 in box 2, if applicable, list the amount each person got for the month from welfare, child support,

and/or alimony.

o For section 3 in box 2, if applicable, list the amount each person got for the month from retirement, Social

Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), and/or disability benefits.

o For section 4 in box 2, if applicable, list Workers’ Compensation, unemployment or strike benefits, regular

contributions from people who do not live in your household, and any other income. Do not include income from

SNAP, FDPIR, WIC, Federal education benefits and foster payments received by the family from the placing

agency. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these

allowances as income.

o If household member does not have an income, check the box indicating ‘no income.’

Part 3: Adult household member must sign the form and list the last four digits of his/her Social Security Number (or mark the box

if s/he doesn’t have one).


In order to help facilitate the eye exam, please complete this brief health history for your child.

Does your child or any immediate family member (parent, grandparent, sibling) have any of the following?

Diabetes No Yes, If yes, who? ______________________________________

Glaucoma No Yes, If yes, who? ______________________________________

High Blood Pressure No Yes, If yes, who? ______________________________________

Does your child have any known ALLERGIES? No Yes, If yes, please list: ______________________________

Is your child currently taking any MEDICATION? No Yes, If yes, please list: ______________________________

Please list any known problems or symptoms your child has in regards to his/her vision and/or eye health: _____________

_________________________________________________________________________________________________________

OneSight is an independent nonprofit providing access to quality eye care and new eyewear in underserved communities worldwide. Since 1988,

OneSight has partnered with local health organizations, governments, school districts, industry leaders, doctors and volunteers to help more than

8.5 million people in 40 countries.

Due to the charitable nature of this program, no breakage protection warranty will be provided on the glasses. Glasses that are lost, stolen or

broken will not be replaced.

Your child is eligible to receive a free eye examination and pair of glasses during camp through our partnership with OneSight.

If your child needs eyewear based on the results of the eye examination provided by a licensed optometrist, a trained professional

will assist your child in selecting a pair of suitable glasses. Both the examination and eyewear will be donated by OneSight.

PLEASE SELECT ONE OPTION IN EACH SECTION BELOW AND SIGN AND DATE THIS FORM.

I Do I Do Not Give my permission for my child to receive a free eye exam and eyewear, if needed, at the

OneSight Clinic during his/her stay at camp this summer.

I Do I Do Not Give my permission for the optometrist to perform a dilated fundus exam during the examination

process at the OneSight Clinic.

A dilated fundus exam is a thorough exam of the peripheral retina aided by the use of topical dilating eye drops. This procedure is

used to diagnose abnormalities of the retina such as detachments, tears, tumors, infections, hemorrhages and genetic

abnormalities. The dilating drops will leave the pupils dilated for approximately four hours. During this period the patient may

experience blurry vision and light sensitivity. Reading may be difficult during this time period.

I Do I Do Not Give my permission for my child to be filmed or photographed and understand that my decision

will not affect whether my child receives an eye exam or glasses.

Release of Liability

I release and discharge from any and all claims, demands and liability arising out of this event or any use granted herein the officers,

directors, employees, agents, affiliates, and/or assigns of the following groups: the independent optometrist(s) who perform the eye

exam; any cosponsoring agency; OneSight, and Luxottica, S.p.A.. By signing below, acknowledgment is given of receipt of

OneSight’s Notice of Privacy Practices. (See information in application package.)

Signature of parent or legal guardian: _________________________________ Date: _____/_____/_____ MM DD YYYY

Child’s last name: _____________________________ Child’s first name: _____________________

Must be Completed & Signed by Parent/Legal Guardian *PAGEN7*


*PAGEA11*

Session 1 June 29 - July 7

Session 2 July 10 - July 21

Session 3 July 24 - August 4

Session 4 August 7 - August 18




First Two Weeks of July

Last Two Weeks of July

First Two Weeks of August

Last Two Weeks of August

If applying to the Career Awareness Program (Camp Mariah) for the first time, indicate your session preference:

1 = MOST preferable and 2 = LEAST preferable

Session 1 June 29 - July 21 Session 2 July 28 - August 18

My child is not available to travel during the following period(s):

From ____________ To ______________

From ____________ To ______________

From ____________ To ______________

Returning campers will attend the same session as Summer 2016

Returning participants only:

Do you want to visit your

Summer 2016 host family if

they are available?

No Yes

Please indicate your session preferences by filling in the boxes with numbers 1-4.

1 = MOST preferable and 4 = LEAST preferable session. We will try our best to accommodate your choices.

Please Note: Children must participate in the full session, and use The Fresh Air Fund arranged transportation. Late arrivals to or early departures from sessions/trips are not allowed.

All applicants:

If my child is not eligible for the Friendly Towns

Program, please consider him/her for the Camp Program

No Yes

All applicants:

Once the Camp Program is full, please consider my child for the Friendly Towns Program

No Yes

As the parent/guardian of the above named child (“My Child”), I agree that My Child may participate in The Fresh Air Fund’s

(The Fund) summer sleep-away programs and associated activities (“Fresh Air Activities”) in either Fishkill, NY or along the

East Coast and Southern Canada, as more fully described in The Fund’s promotional materials. I permit My Child to travel

between The Fund’s designated transportation hubs and the assigned program location by bus, train, automobile, plane,

taxi, car service, subway, or any other means necessary. I understand that participating in Fresh Air Activities is wholly

voluntary. Additionally, I permit My Child to participate in the Fresh Air Activities including, but not limited to: camping,

swimming, boating, rope and challenge courses, biking, hiking, and other activities described and shown in brochures and

other marketing materials.

I understand that I may receive as much information from The Fund with respect to the Fresh Air Activities as I deem

desirable, and will have the opportunity to discuss the Fresh Air Activities with members of The Fund’s staff and/or volunteers prior to My Child participating in the Fresh Air Activities. I understand that I am responsible for making my own

independent assessment of the risks to My Child of participation in the Fresh Air Activities, including the risks associated

with travel, camping, swimming, boating, rope and challenge courses, biking, hiking and other activities included in the Fresh

Air Activities.

I am aware that travel and the activities included in the Fresh Air Activities can be dangerous and can involve risks of serious

injury and even death. I understand that, although Fund Agents (as defined below) will chaperone the Fresh Air Activities,

My Child will be unsupervised at times during participation. I agree that The Fund is not an insurer of the health or safety of

My Child. I also agree that The Fund does not assume responsibility for spontaneous and unforeseen events that may occur

during My Child’s participation in the Fresh Air Activities.

In consideration of the The Fund permitting My Child to participate in the Fresh Air Activities:

I, on behalf of My Child, myself, my spouse, my domestic partner and all other family members and the heirs, agents,

executors, administrators, representatives and assigns of each of the foregoing and all persons claiming under them

(collectively, the “Child Parties”), assume all risks involved in the Fresh Air Activities. I agree that neither the The Fund nor

any of its former, current and future directors, officers, employees, volunteers, affiliates and agents (each of the foregoing, a

“Fund Agent”) (including each Fund Agent who participates in the planning, organization or implementation of the Fresh Air

Fund Activity) shall have any responsibility for any injury to person or property, illness, loss of life or property, liability,

damage, expense or other adverse event that may occur during the Fresh Air Activities, other than as the direct

consequence of any gross negligence or willful misconduct of The Fund or any Fund Agent.

I, on behalf of My Child and the other Child Parties, do I agree that neither the The Fund nor any of its former, current and

future directors, officers, employees, volunteers, affiliates and agents (each of the foregoing, a “Fund Agent”) (including each

Fund Agent who participates in the planning, organization or implementation of the Fresh Air Fund Activity) shall have any

responsibility for any injury to person or property, illness, loss of life or property, liability, damage, expense or other adverse

event that may occur during the Fresh Air Activities, other than as the direct consequence of any gross negligence or willful

misconduct of The Fund or any Fund Agent. I understand that, as a result of my executing this release, I and the other Child

Parties shall be forever barred from suing or otherwise asserting a claim, demand or cause of action against The Fund and

the Fund Agents to the extent provided above.

I hereby represent and warrant to The Fund that I am authorized to sign this Consent and Release Form on behalf of Child Parties and to bind them hereby.


Must be Signed by Parent/Legal Guardian


Signature: _________________________________________________ Date: _____/_____/_____

Print Name: _______________________________________________

MM DD YYYY




As the parent/guardian of the above named child, my signature on Page 12 of this application affirms that:

A) I give the following permissions to The Fresh Air Fund:

1. To use photos and/or videos of my child and his/her first name in public relations efforts, including, but not limited to print and elec-

tronic media and ads, and social media platforms.

2. To contact third party providers (e.g. caseworkers, counselors, therapists, social workers, medical physicians, or referring agencies -

community based organizations, schools, churches, and hospitals) as identified in the application or evaluation consent form, if a con-

sultation is necessary to complete the application.

3. To receive information regarding my child from their service provider if s/he has an IEP and/or is receiving services (special education,

supportive services, therapy, counseling etc.).

4. To discuss my child’s health history with the medical provider indicated on the medical form submitted with the application.

5. To share my child’s health form and medical information directly with a third party program (e.g. camp) if the Host Family in the

Friendly Towns Program sends my child to a third party program during his/her trip.

B) Should my child require medical treatment during his/her participation, The Fresh Air Fund and its Agents have the following

permissions:

6. To provide the Host Family with a copy of my child’s health insurance card while s/he is in the Friendly Towns Program.

7. Full authority to take the actions deemed necessary to ensure my child’s health and safety, including: delivering routine and ensuring

emergency health care; dispensing/administering medications; and seeking medical or dental treatment for my child, if necessary,

while s/he is away.

8. To release any medical or other records necessary for treatment, referral, billing, or insurance purposes by The Fresh Air Fund to

other medical personnel treating my child.

9. To obtain medical care and treatment as may be deemed necessary for the health and safety of my child by duly licensed physicians,

nurses, or qualified medical personnel of any hospital, urgent care facility, or clinic.

10. To share my child’s health record with duly licensed physicians, nurses, or qualified medical personnel of any hospital, urgent care

facility, or clinic.

11. To share my child’s health insurance information (medical and/or dental) with any provider of medical services to my child.

12. To use my child’s health insurance as the primary coverage for any medical treatment s/he receives while participating in The Fresh

Air Fund’s program(s).

C) I acknowledge that:

13. I am responsible for my child’s transportation to and from his/her program’s departure and return site, and that s/he will only be re-

leased to an adult, aged 18 or older, named on Page 1 or 2 of this application. I acknowledge that only those participants who are 17

years of age or older may sign themselves out upon arrival at the return site with prior parental permission.

14. I have read, or have had explained to me, information about meningococcal meningitis disease and vaccination included in the appli-

cation package, and I confirm that I understand the risks of not having my child vaccinated.

15. My child may use sunscreen s/he has brought to Camp/Friendly Town or that Camp/Friendly Town has supplied, which is approved

by the FDA for over-the-counter use to avoid overexposure to the sun. Sunscreen may be applied by camp staff or host volunteer if

my child requests.

16. In addition to calls from The Fresh Air Fund’s staff and volunteers, information may be sent by email, text or automated phone calls.

17. My child must comply with all program rules and standards including, but not limited to: house/cabin rules; cell phones, electronics

and technology; and pool safety. His/her failure to do so may result in an early end to his/her summer experience. I understand that in

the event of an early return, I will be required to pick my child up from The Fresh Air Fund’s office and participate in an exit interview

with my child and a Fresh Air Fund Social Worker.

18. My child’s health insurance will be the primary coverage for any medical treatment s/he receives while participating in The Fresh Air

Fund program, and that I may be responsible for fees for hospital, nursing, medical and surgical services that exceed the amounts

covered by my child’s health insurance.

19. Depending on the nature of the illness or condition, it may be necessary for my child to return home early from his/her summer experi-

ence for medical treatment.

*PAGEA12*

Documents

Camp *PAGEA1* - The Fresh Air Fund / Home Child Application... · If we are unable to reach you, we will call the contacts in the order listed below. Emergency contacts must be 18

Camp PAGEA1 - The Fresh Air Fund / Home Child Application... · If we are unable to reach you, we will call the contacts in the order listed below. Emergency contacts must be 18