Name of attending magical student
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Birthdate
MM
DD
YYYY
Age at start of session
*
Height and weight
Parent/Guardian #1
*
First Name
Last Name
Relationship to student
Best phone
*
(###)
###
####
Email
*
Parent/Guardian #2
First Name
Last Name
Relationship to student
Best phone
(###)
###
####
Email
Emergency contact other than parent/guardian
*
First Name
Last Name
Best phone
*
(###)
###
####
Email
*
Relationship to student
*
Do you have medical insurance?
*
If yes, name of carrier or plan
Name of insured
*
First Name
Last Name
Policy number and Group number
Insurance company phone number
*
(###)
###
####
Name of physician
*
First Name
Last Name
Phone number of physician
*
(###)
###
####
General Health History
*
Please check all statements that apply to your student
Please further explain anything checked above regarding general health history and how it may effect your child's experience at Fiddleheart.
Mental, Emotional and Social Health
Please check all statements that apply to your child
Please further explain anything checked above regarding mental, emotional and social health and how it may effect your child's experience at Fiddleheart.
Allergies: Does your child have allergies?
*
If yes, what is your child allergic to?
If yes, please specify the allergy. What is the reaction and the plan?
Is an Epipen or Auvi-Q necessary?
*
If yes, under what circumstance would use of the Epi-pen or Auv-Qi be necessary
Does your student use a rescue inhaler?
If yes, under what circumstances is your student most likely to need the rescue inhaler?
Medications: Does your student take medication daily? If yes, what kind and at what dosage?
Medication refers to any substance a person takes to maintain and/or improve their health.
Medications during the camp day: Does your student require medication during the day while attending Fiddleheart?
Medication refers to any substance a person takes to maintain and/or improve their health.
If you checked yes, the state of NJ requires original pharmacy containers with labels showing the student's name and how the medication should be given. Please provide the following details regarding medications: Name of medication, date started, reason for taking it, when it is given, amount or dose given and how it is given.
The medication will be kept in the health center for the duration of the session.
If your child requires medication during the camp day, please agree to the following Medication Dispensing Authorization~ I hereby request and authorize the administration, to my child, of the above prescribed medication by the non-medically trained Fiddleheart staff member selected by the camp director.
Fiddleheart will have the following non-prescription medications available in the health center and are used on an as needed basis . Please check off all medications that are NOT to be given to your student while attending Fiddleheart.
In the event that it is determined that any of the above, unchecked, over-the counter medications are indicated, please agree to the following Medication Dispensing Authorization~ I hereby authorize the administration, to my child, of the above, unchecked, over-the-counter medications, by the non-medically trained Fiddleheart staff member selected by the camp director.
Is there anything else that you would like us to know about your child's medical history, mental-emotional (and magical!) history and/or current conditions and life situations?
We intend to be sensitive to and meet the unique needs of your child to the best of our ability and can only do so if we have the information that would assist us .
Parent/Guardian /Staff Authorization: This health history is correct and complete as far as I know, and the person herein described has permission to participate in all camp activities except as noted. I hereby give permission to the medical personnel selected by the camp director to order x-rays, routine tests, treatment, to release any records necessary for insurance purposes; and to provide or arrange related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization for the person named above. This form may be photocopied for trips outside of camp.
*
Digital Signature
*
By typing in your name, you are providig a digital signature.
First Name
Last Name
Date Signed
*
MM
DD
YYYY
Woo-hoot!
Let the sparks fly from the end of your wand!
You have completed Step 3 of the registration process.
Thank you for submitting your Medical Form.
Last but not least….although it takes more than a wave of the wand, please email your child’s up-to-date immunization record and copy of covid vacinne card to headmistress@fiddleheartmagic.com. NJ state law requires students to have up-to-date immunizations to attend summer camps and Fiddleheart must have these records on file. Thank you!
Just to be certain....
Did you also...?
1. Complete your payment
2. Submit your Registration Form
CONGRATULATIONS!
You are fully registered!
We look forward to sharing a magical summer with you!
If you have any remaining questions, please go here to email us or call the Headmistress at 917-687-1859.
