All medications brought by the camper
(prescription or over-the-counter)
must be given to the
camp health officer at the time of check in. The health officer stocks the most common medicines
such as Tylenol and cold remedies, so it is unnecessary to bring them.
All medications must be
in the original container and include clear and current directions and the camper’s name.
Asthma inhalers may be kept by the camper, as needed.
Campers are not allowed to bring alcohol, cigarettes, drugs, weapons, fireworks, cell phones,
or electronic devices (except cameras). Camp Henry reserves the right to search any camper’s
belongings and confiscate these items.
Camp Henry provides secondary accident insurance for campers during their time at camp. Camp
Henry’s insurance begins where yours leaves off. Illness and sickness are not covered. Any outside
charges incurred related to this illness will be billed to parents or guardians.
I understand it is the policy of Camp Henry not to release a camper to anyone other than the
person designated at the beginning of camp. I recognize that certain hazards and dangers are
inherent in camp events and programs, and particularly, but not limited to, horseback riding,
hayrides, swimming, boating, A-field activities, ropes courses, team courses, tower climbing, water
skiing, sledding, and canoeing. I understand that adventure activities may expose my child to
psychologically and physically stressful and challenging situations.
I understand, too, that although the program has taken precautions to provide proper
organization, supervision, instruction, and equipment for each activity, it is impossible for the
program to guarantee absolute safety. I understand that my child shares responsibility for his/
her safety and I have instructed my child in the importance of knowing and abiding by the
camp rules, regulations, and procedures for the safety of camp participants. Further, I waive any
claim that may arise against Camp Henry and/or its employees as a result of participation in the
program, except for those which are the direct result of the gross negligence of Camp Henry or its
employees. Camp Henry reserves the right to discipline or send home any child for any reason at
its sole discretion, including rule violations or health and safety concerns.
In signing this document, I hereby certify that the included information is correct, and give
permission for the use of photographs, or other media, including my son or daughter to be used in
camp publicity; for my son or daughter to be transported for approved out-of-camp activities, and
for the release of medical information in case of illness. In the event I cannot be reached, I hereby
give permission to the physician selected by the Camp Henry staff to obtain proper medical
diagnosis, hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for
my child named above. If an injury should occur at Camp Henry, I understand that Camp Henry’s
insurance coverage picks up where my insurance leaves off, up to the limits of the camp.
CAMP HENRY EQUINE LIABILITY RELEASE /
Please read the following agreement and liability
release for horseback riding and or horse-related activity at Camp Henry before signing.
WARNING /
Under the Michigan Equine Activity Liability Act, an equine professional is not liable
for an injury to or the death of a participant in an equine activity resulting from an inherent risk of
the equine activity.
As a guest at Camp Henry, I, the undersigned, recognize that Camp Henry is located in a rustic
setting with natural and artificial hazards (including surface and subsurface conditions). The
undersigned also understands that it is the propensity of an equine to behave in ways that may
result in injury, loss, or death. Equines can act unpredictably to sounds, sudden movements,
unfamiliar objects, persons, or other animals. It is also understood by the undersigned that there
could be a collision with another equine, animal, person, or an object while riding on Camp Henry
premises.
The undersigned will be given basic riding instruction prior to riding, yet there is a potential for
the participant to act or fail to act in a manner that could contribute to injury, loss, or death. I
understand that by mounting a horse and by taking the reins that the rider is in primary control of
the horse. The rider’s safety largely depends on his/her ability to carry out simple instructions and
his/her ability to remain balanced aboard the moving equine.
I/We, the undersigned, have read and do understand and agree to the foregoing agreement,
warnings, waiver, and the assumption of risk. We assume the risk of injury from the above danger,
and waive liability, if any, of Camp Henry/Westminster Presbyterian Church of Grand Rapids, MI
and its staff and volunteers.
__________________________________________________/__________________________________/
Authorized Signature / Parent or Guardian
Required
Date of Signature
For Camp Henry Use Only
/ Health review form to be completed by the Camp Henry Health Officer within 24
hours of camper’s arrival.
Initials
______________/
Date of Signature
________________/
Prescription Medications and any Non-prescription/OTC Medications
(You will be able to update this list when you deliver your child to camp)
Please list
_______________________________________________________________________________/
________________________________________________________________________________________/
This Health History is REQUIRED for registration.
This info is not part of the acceptance process, but is
gathered to assist us in identifying appropriate care. Please check appropriate spaces and fill in all info as
completely and accurately as possible.
Allergies / List All
_________________________________________________________________________/
Yes No I hereby give my permission to the Camp Health Office to provide any first aid for the
mild injuries and illnesses that should arise for the child named above.
Yes No I also give my permission to administer over-the-counter medications, including:
Tylenol, Motrin, allergy/cold medications, gastrointestinal medications (e.g. Mylanta,
laxatives, anti-diarrhea) and lotions/creams (e.g. sunblock, Benadryl cream,
hydrocortisone) except for the following
_______________________________________/
__________________________________________________________________________/
Physician
___________________________________________/
Phone
_____________________________/
LastPhysicalExam(musthaveoccurredwith24months)
_________________________________________/
Dentist/Orthodontist
_________________________________/
Phone
______________________________/
Health Insurance
________________________________________________________________________/
Policy/Group #
___________________________________/
Authorization Phone
_____________________/
Date of last Tetanus (Required)
______________________________________________________________/
Polio
______________________________________/
Varicella
___________________________________/
Hepatitis B
___________________________/
MMR (Measles, Mumps, Rubella)
________________________/
Camper’s Name
______________________________________/
Male or Female
/
Birth Date
_________/
Parent/Guardian
______________________________________/
Cell Phone
________________________/
Non-Parental Emergency Contact
__________________________________________________________/
Relationship
_________________________________/
Phone
_____________________________________/
Overall Health?
___________________________________________________________________________/
Are there any medical problems, previous or current? (ie. Diabetes, asthma, seizure disorder, etc.)
Yes No
If yes, please explain in detail
_____________________________________________/
List any surgeries or hospitalizations and year
________________________________________________/
Any special health and/or behavioral considerations and/or physical limitations?
_______________/
_____________________________________________________________________________________/
HEALTH FORM
SEND COMPLETED REGISTRATION/HEALTH FORM WITH PAYMENT TO:
Camp Henry
5575 Gordon Ave. / Newaygo, MI 49337
tel
616.459.2267
fax
231.652.9460
web
email
PLEASE PRINT
