2008 Des Moines County Conservation
Day Camps
Medical and Emergency Information Form
Please Use One Form Per Child - Do Not Put More Than One Child Per Form

Child’s name:   Age:   Birth date:  
   
Name of Parent or Guardian  
   
Address:   City:   State:   Zip:  
               
Daytime Telephone:     Evening Telephone:  
         
Name of Camp:           Dates of Camp:  
         
Alternative Emergency Contact:     Phone:  
 
List any medical conditions or allergies of which we should be aware:
 
 
Will your child be taking any medication during the time she or he is participating in the programs at Starr’s Cave Nature Center?  If so, please list the name and its purpose.
 
Does your child have any food allergies or dietary restrictions? Please explain.
 
Note: All of the information will be kept strictly confidential.  It is for use by the staff of  Starr’s Cave Nature Center alone.
 
  has my permission to participate in 2008 Summer
                               (name of child)  
   

Camp programs at Starr’s Cave Park & Preserve and other Des Moines County parks.  I hereby grant permission for the staff of the Des Moines County Conservation to administer any needed first aid and to summon medical professionals in the event of an emergency.  I also grant permission for possible photos of my child to be used for marketing purposes for Des Moines County Conservation.
 
     
                    (signature of parent or guardian)                                            (date)
     
Please return this form to Partners for Conservation, 11627 Starr’s Cave Road, Burlington, IA 52601, prior to the beginning of the program for which your student is registered.