Elodie Farms Summer Camp

Emergency Contact and Permission Form

Elodie Farms

Emergency and Permission Form 
 

Child’s Name       Age     DOB_____________                      

Parents/Guardians___________________________________________________________                                                                                                                 

Address   _____________________________________________________________           

Home Phone______________Work Phone______________ Mobile Phone__________ 
 

Medical and Emergency Information 

General Health ______________  Date of last Physical ____________________ 

Physical Limitations _____________________________________________________ 

Known Allergies ________________________________________________________ 

Medications ____________________________________________________________ 

Physician’s Name__________________________________Phone ________________ 

Dentist’s Name ____________________________________Phone _______________ 
 

If Elodie Farm’s staff is unable to contact primary parents/guardians in an emergency, please provide the names of at least two other people who will be available during camp hours. 

Name ____________________________  Relationship___________Phone_________ 

Name ____________________________  Relationship___________Phone_________ 
 
 

Parent’s/Guardian’s Signature______________________________Date____________     

Permission for Specific Activities 

Please read carefully and initial all that will apply to your child. 

_____  I give ____ I do not give permission for the staff of Elodie Farms to call EMT personnel to treat, stabilize and or transport my child in case of medical emergency. 

_____  I give ____ I do not give permission to the staff of Elodie Farms to administer the following medication per my instruction including medicine name, dosage, time, and circumstance.  All medicine must be in original pharmacy container:  ____________________________________________________________________________________________________________________________________________ 

_____  I give ____ I do not give Elodie Farms’ staff permission to administer non prescription medicine (antibacterial ointment, peroxide, iodine, betadine, rubbing alcohol, sunscreen, burn cream, calamine lotion, appropriate bandaging, antibacterial soap, etc.) for treatment of minor injuries. 

_____  I give ____ I do not give permission for my child to participate in any and all classes and activities which are age and developmentally appropriate while supervised by Elodie Farms’ staff except the following _____________________________________________________________________ 

_____  I give ____ I do not give permission for my child to participate in swimming and canoeing in the designated areas of the pond.  I understand a certified lifeguard will be present, but that does not eliminate the risks and dangers associated with swimming in non-transparent water.  I understand my child will be exposed to those risks and dangers if they participate in water activities. 

_____  I give ____ I do not give permission for my child to participate in wood working.  He/she is age and developmentally appropriate for this activity.  I understand that my child will be under the supervision of Elodie Farms’ staff, but that supervision can not always avoid or prevent certain risks and dangers associated with being around tools and machinery. 

_____  I give ____ I do not give permission for my child to ride and care for horses while under the supervision of Elodie Farms’ staff.  I understand the risks and dangers associated with being around horses can not always be avoided and that my child may be exposed to such risks.  
 
 
 
 

WARNING 

Under NC law, an equine activity sponsor or equine professional is not liable for an injury to, or the death of a participant in equine activities resulting exclusively from the inherent risks of equine activities.  (Chapter 99E of NC General Statutes). 

Under NC law, there is no liability for an injury or death of a participant in an agritourism activity conducted at this agritourism location if such injury or death results from the inherent risks of the agritourism activity.  Inherent risks of agritourism activities include, among others, risk of injury inherent to land, equipment, and animals, as well as the potential for you to act in a negligent manner that may contribute to your injury or death.  You are assuming the risk of participation in this agritourism activity.  (GS 2006-236)