Parent/guardian agreement

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1031 Erickson Road  P.O. Box 185

Ashby, Massachusetts 01431-0185


Please place a check mark in each of the boxes of each section that you agree to and sign below.
YES…In case of sickness, I wish my child to be held at the camp’s First Aid Facility. I understand that all the first aid procedures are located in the Camp Middlesex Parent Handbook.
YES…I authorize the Camp Nurse or Directors to administer the following non-prescription medications, as checked below. (Please check off below which non-prescription medications you give permission to be administered by the Camp Nurse to the below named camper on an as needed basis. All over the counter medications for campers shall be kept in the original containers containing the original labels, which shall include directions for use).

  • Acetaminophen (Tylenol): To relieve headaches, minor aches, fever, and menstrual cramps. Contains no aspirin.

  • Ibuprofen (Motrin/Advil): To relieve headaches, toothaches, minor aches, fever, and menstrual cramps. Contains no aspirin. *Caution: people with a severe allergic reaction to aspirin must not take ibuprofen.

  • Dyphenhydramine (Benedryl): Contains antihistamine for temporary relief of sneezing, runny nose, itchy eyes and throat due to allergy and colds and/or pain & swelling due to insect bites.

  • Cough Drops: Quiets coughs.

  • Antacids (Tums): Provides temporary relief of acid indigestion and/or nausea.

  • Sunscreen/insect repellant (may be applied by counselors, if needed)

  • Topical ointments (Bacitracin, Calamine, Hydrocortisone, burn gel containing aloe/lidocaine): To protect against infection or relieve itching/pain from insect bites, rashes, or superficial burns.

YES…In the event of apparent serious illness, I authorize 4-H Camp Middlesex to send him/her to the nearest hospital. 4-H Camp Middlesex uses the Ashby Fire Department Ambulance Service to transport any child in need of emergency care. The ambulance service transports to Leominster or Deaconness-Nashoba hospitals only. If I wish my child to be cared for at a different facility it will be my responsibility to transfer my child from one of the aforemententioned hospitals. I shall be responsible for charges incurred either through home health and accident insurance or Medicaid. I understand I will be notified of any illness/accident as soon as possible. For serious injuries or concerns not requiring an ambulance, the camp will send the child to the Urgent Care facility in Fitchburg, or Leominster Hospital.

YES…I grant permission for my child to participate in ALL camp activities and programs at 4-H Camp Middlesex.
YES…I grant permission for my child to leave camp grounds to attend the Wednesday night band concert in Ashby Center. I also grant permission for my child to walk to the Ashby Basketball courts (depending on program schedule), and to attend the weekend trip (as advertised) if my child is staying over the weekend.
YES…I authorize 4-H Camp Middlesex to have and use photographs, slides, and recordings of my child as may be needed for records or public relations. Please note: Campers that do not have this section checked off will not be a part of the group photo that is taken on Monday.
YES…I authorize the release of DVD/videos that feature my son/daughter taken during program areas that may include video images of my children. Please note: All performances and video production classes are recorded. Campers that do not have this section checked will not be allowed to participate in these programs so that we may release the recordings.
YES..I understand that 4-H Camp Middlesex reserves the right to cancel camp programs should

Government action or other circumstances make camp operation impossible. 4-H Camp Middlesex also reserves the right to decline to accept an application and to dismiss a camper from camp. Under suspicions of theft and possessing camp banned substances, Camp Middlesex administration reserves the right to search through a camper’s belongings.

____________________________________ ______________________

Camper’s Name Group & Session
_____________________________________ _______________________

Parent/Guardian Signature Date

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