Summer ZooCrew Check the weeks you would like to sign your child(ren) up for ZooCrew: 4 & 5 year olds* Week of 7/18 In My Backyard Week of 8/1 Once Upon a Story Week of 8/15 Where the Wild Things Are 6 & 7 year olds Week of 7/18 Pollination Nation Week of 7/25 Where in the World Week of 8/8 Mythical Creatures 8 & 9 year olds Week of 7/11 Sense-sational Animals Week of 8/1 Animal Mythbuster Week of 8/15 Survivor: Air 10 & 12 year olds Week of 7/11 Wildlife Warriors Week of 7/25 Great Adaptations Week of 8/8 ZooCrew Trekkers $200/week for Zoo Members; $225/week for non-zoo Members *4 & 5 year old programs also have a half day option that runs from 9am-12pm $100/week for Zoo Members; $115/week for Non-Zoo Members Included in the price of each session is 1 Zoo Crew t-shirt. This t-shirt will stay at the Zoo for the week and go home with the child on Friday. Additional t-shirts may be ordered at $12 each. Circle the size of t-shirt wanted: youth small youth medium youth large youth x-large adult small Circle the size for sibling t-shirt: youth small youth medium youth large youth x-large adult small Number of additional shirts: @ $12/each= total for additional t-shirts Total Fee: Please check payment type: Check: Please make checks payable to the Buttonwood Park Zoological Society, Inc. MasterCard: Visa: Discover: Card #: 3 Digit Security Code: Exp. Date: Signature: Today s Date:
Child s Name: Sibling s Name: Age: Age: Parent/Guardian s Name: Address: City: State: Zip: Email address: Phone Number: Emergency Contact Information Please note that the following information will be kept in the strictest confidence and will be destroyed at the end of this season s ZooCrew sessions. In the event of an emergency, we will need to contact the child s primary caregiver. Please provide the following information: Child s primary caregiver: Relationship to child: Work phone: Home phone: Cell phone: Which should we try first? In the event the primary caregiver cannot be reached, whom should we contact? Name: Relationship to child: Work phone: Home phone: Cell phone: Which should we try first? In the event of an emergency do you give the Buttonwood Park Zoo, and its staff, permission to notify the proper authorities and/or accompany your child to the appropriate facilities for treatment? YES NO (Please note: marking NO will disqualify your child from the program) Signature Relationship to child(ren) Date
General Release Permission Form Child s Name: DOB: Sibling s Name: _ DOB: In consideration for the services rendered to my above named child(ren), I specifically release and hold harmless the Buttonwood Park Zoo, its agents, servants, and employees from any and all liability, claims, damages, and causes of action I may now or hereafter have as parent of said minor(s). Further, I hereby give permission for my said child(ren) to engage in any and all programs and activities at the Buttonwood Park Zoo. Signature (required to attend) relationship to child(ren) Date I hereby give permission for photographs and video to be taken of my child(ren) in context with the program to be used by the Buttonwood Park Zoo and Buttonwood Park Zoological Society for publication purposes. Signature (optional) relationship to child(ren) Date
Allergy and Medical Form Allergies: No known allergies This child is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other Please list 1) what the child is allergic to, 2) the reaction seen, 3) how to manage the reaction, 4)if any medications are brought to the program you must complete page 5. Health History If your child has any special conditions, needs or limitations please speak with the ZooCrew Director Has/does the participant: Yes No Had a recent injury, illness or infectious disease? Have a chronic or recurring illness/condition? Had diabetes or problems with blood sugar control? Been hospitalized/surgery within past 2 years? Have frequent headaches? Ever had a head injury? Had a seizure? Wear eyeglasses, contacts or protective eye wear? Had fainting or dizziness? Had asthma/wheezing? Note type and severity below Have any skin problems (rashes, severe acne)? Had mononucleosis in the past 12 months? Have motion sickness? Ever been stung by a bee? Ever been treated for Lyme Disease? Ever been treated for ADD or ADHD? Have frequent stomachaches? Have problems with constipation/diarrhea? Ever been treated for an eating disorder? Passed out/had chest pain during or after exercise? If female and of appropriate age, have problems with periods/menstruation? Have frequent bloody nose? Ever been treated for emotional or behavioral difficulties? Explain any yes answers, noting the number of the question.
To better serve your child, please share any information about his/her behavior, physical, emotional or mental health about which we should be aware. These may include shyness, socialization difficulties, issues with stress, learning style, etc. Please list strategies used to manage the concern and/or to enhance your child's ability to be more successful and happier while with us. When your child is upset, how do you calm him/her down? At-Home Medications 1) Please list the condition and medications taken at home (Example: Hay fever-claritin). 2) Any medications to be taken during the hours of the program must be listed on page 5. No medications taken on a routine basis. Taken Daily: Taken Seasonally: As needed: Name of child s physician: Phone Number:
POLICY AND INSTRUCTIONS FOR MEDICATION ADMINISTRATION 1. All information on form below must be completed and signed by a legal guardian for medication to be administered to camper while attending Buttonwood Park ZooCrew. 2. Medications to be refrigerated must be identified when given to the Camp Director. 3. By law, all medications must be in the original container with prescription label in place and legible, including: date of filling, pharmacy name and address, the filling pharmacist s initials, the serial number of the prescription, name of the patient, name of prescribing practitioner, name of the prescribed medication, directions for use, and cautionary statements, if any, contained in such prescription or required by law, tablets or capsules, the number in container. Prescription medication will not be administered if medication(s) are not in original prescription container. All over the counter medications for participants must be in the original containers containing the original label, which shall include the directions for use. 4. All medications will be kept in the First Aid Room of Buttonwood Park Zoo unless they must be administered immediately in an emergency. 5. The prescription medications listed below will be the only prescription medications administered. 6. Camp Counselors will bring participants to the First Aid Room. 7. All medications to be given must be noted on the Medication Permission form. Name of Child Name of Medication Dosage Time(s) to be Given Reason for Medication Special Instructions Parent/Legal Guardian Signature Date ADMINISTRATIVE USE ONLY Accepted by: Location of Medication: Date Returned to Guardian:
Medical Waiver and Authorization Agreement to these terms is a required for participation. 1) Medical release: This Health History is correct and complete as far as I know. I hereby give permission to Buttonwood Park Zoo staff to provide routine healthcare, administer prescribed and over-the-counter medications as described, and seek emergency medical treatment for the my child named above. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. I give permission to Buttonwood Park Zoo staff to arrange necessary related transportation for my child named above. In case of a medical emergency, every reasonable effort will be made to contact me. In the event that I cannot be reached, I hereby give my permission for the medical personnel selected by Buttonwood Park Zoo s designated healthcare staff to secure and administer medical treatment including to hospitalize, order and administer medications and anesthesia, perform X-rays, special procedures, or surgery, if deemed medically necessary for my child named above, for which charges I shall be responsible and agree to pay. 2) Medications: Pursuant of Massachusetts state law and Buttonwood Park Zoo s policy, I authorize the At- Program Medications listed above to be administered by Buttonwood Park Zoo s designated healthcare staff, as directed, to my child for whom it was prescribed. I understand that all medications, prescribed and over-thecounter, must be in their original containers and be labeled with specific instructions, including the person's name and dosage, and that the pharmacy label must be on all prescribed medications. 3) Off-site Trips: I give permission for my child to participate in and be transported to any off-site trips as scheduled. This completed form may be photocopied for off-site trips. (Relevant on to the ZooCrew Trekkers program). As the parent/legal guardian of the participant, have read, understood, and agree to the above. Signature of parent/legal guardian Printed Name Date
Health Care Record to be completed by licensed medical personnel Instructions for Parents/Legal Guardians: If your physician has given you a form containing a record of the most recent physical and immunization record, send a copy to ZooCrew at the Buttonwood Park Zoo as soon as possible. If you do not have a copy, please send this page only to your provider s office. It is your responsibility to receive this page back and submit it to ZooCrew at Buttonwood Park Zoo before the registration deadline. A physical exam with 24 months (2 years) is requested for each camper and camp staff. Immunizations must be up-to-date as directed by the Massachusetts Board of Public Health and both recorded and signed by licensed medical personnel. If for religious reasons you are not able to complete this section, please contact us today. We will provide you with a waiver to sign. Camper Immunization Requirements of the Massachusetts Board of Public Health Campers must meet the regulations for the grade they are entering. Regulation: 105 CMR 430.152 Exception: Those entering Kindergarten may meet the Preschool requirements for summer camp. # doses/grade Pre Kinder Grades 1-6 Grades 7-12 DTaP/DTP/DT/Td 4 5 4 1 Td booster (not gr.11+) Polio 3 4 4 3 Hepatitis B 3 3 3 (none if born before 1/1/92) MMR 1 measles 2 measles 2 measles 2 measles 1 mumps 1 mumps 1 mumps 1 mumps 1 rubella 1 rubella 1 rubella 1 rubella 1) Healthcare provider must provide documentation of the immunizations. (2) Serologic proof of immunity is acceptable in lieu of immunization. (3) Exemption due to religious reasons is allowed, but parent/guardian sign a waiver. Contact the camp director. Patient's Name: DOB Last First Middle Has been examined on BP Weight Height Known medication allergies Known food allergies Other allergies _ Dietary restrictions Medications Name Dosage Frequency Reason for taking 1. 2. 3. 4.
No apparent contraindication exists to full participation in: Routine camp activities Camp employment Restrictions to camp activities: Additional information for healthcare staff at camp: Disease history: Date of disease Measles Mumps Rubella Hepatitis A Hepatitis B Hepatitis C Mononucleosis Immunization record: Vaccine: Dates: Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr DTP TD (tetanus/diptheria) Tetanus Polio MMR or Measles or Mumps or Rubella Hemophilus influenza B Hepatitis B Varicella or date of disease Tuberculin: Low risk Date of last test Positive Negative Signature of Licensed Medical Personnel Date Printed name Title Name of Practice Address Phone