Youth Health & Release Forms
Audubon Center of the North Woods


Student’s Name___________________________________ Age:________ Gender:_____ M ____ F

Student’s Date of Birth___________________

Parent or Guardian_______________________________________

Home Address_______________________________City_______________________State:_____Zip:_________

Home Phone:___________________ Business Phone: _________________________

e-mail__________________________________________

Name of Health Insurance:_________________________________________ Policy#______________________

Family Physician:_____________________ Physician’s Phone: ( )______________________

In an emergency, if unable to reach parent/guardian, contact:

Name:______________________________________ Phone:_______________________

Address____________________________________City:_____________________State:______Zip_________


Medical Information

1. Is the student taking any medication at the present time?.......................…. YES NO
If yes, please explain____________________________________________
2. Has the student had recent surgery or illness?.....................................….…YES NO
If yes, please explain____________________________________________
3. Has the student been exposed to a contagious disease recently?.............. . YES NO
If yes, please explain____________________________________________
4. Does the student have any allergies?......................................................... YES NO
If yes, please explain____________________________________________

5. Does the student have a history of any of the following:

Sleep walking........................ YES NO
Bedwetting............................ YES NO
Fainting.................................YES NO
Diabetes............................... YES NO
Asthma................................. YES NO
Food restrictions.................... YES NO
Other medical conditions........ YES NO If so, what? ____________________________
6. Are there any other directions or information from the parent/guardian.......... YES _____ NO _____
If yes, please explain _____________________________________________________________

 

Immunization History
Students must be fully immunized prior to attending a residential program at the Audubon Center.
Are all school required immunizations up to date ( MMR, DPT, TB booster, Polio, Hep B)
YES_______ NO_______
If NO, please explain_____________________________________________________________


Medical Release
If a serious emergency occurs, it might be necessary for a physician to attend your child before
you can be contacted .

This care can be provided only if you sign the authorization below. Either the authorization or a statement
of the reasons for not allowing it should accompany this health form and be signed.

I hereby authorize the official representative of my child’s school or the person in charge at the
Audubon Center to obtain medical or surgical care for____________________________ while
he/she is in attendance at the Audubon Center.
Parent/Guardian Signature: ________________________________________ Date:_________________

I hereby give my permission for non-prescription medication (aspirin free) to be given to my child is
deemed advisable by teachers, chaperones, or Audubon Center staff.

In case of emergency, I hereby give my permission to the physician selected by my child’s teacher
or Audubon Center staff to treat and care for my child.
Parent/Guardian Signature:_________________________________________ Date:__________________

Risk Waiver
The Audubon Center takes all possible measures to keep participants safe. However, there is a risk
of injury possible on a trip such as this one. I acknowledge and accept the risk, and will not hold the
Audubon Center or the school and its employees liable unless there is negligence proven.

Signed:____________________________________________________.Date:_______________________
Parent or Guardian if participant is under 18 years of age

Field Trip Permission and Accident Waiver Form Permission
___________________________________________ has my permission to participate in the
residential program at the AudubonCenter (and partner facilities if applicable). I understand the
arrangements and feel the necessary precautions and plans for the care and supervision of the
students during the trip will be taken. Beyond this, I will not hold the school or those supervising
the trip responsible. I give permission for the group leaders to transport my child for education or
emergency purposes. I also give permission for any photographs taken during the trip to be used
for promoting or advertising the program at the Audubon Center.
Signed:_______________________________________________ Date:____________________

Photo Release Permission
The undersigned hereby allows the Audubon Center of the North Woods to use photographs of
the participants taken during the Audubon programs for use in promotional materials.
Signature of Participant: _______________________________________ Date: ___________________

Signature of Parent/ Guardian :___________________________________ Date: __________________