Family Application

Family Application

Confidential Health and Release Form
We ask that you give us some rather detailed information that will help our staff to best provide programs and supervision for your teenager. The information will be reviewed and passed on to your teenager’s counselor. You know your teen best and your answers will help us provide the best possible experience. The intent of this information is also to provide Ranch health care personnel the background to provide appropriate care. Please provide complete information so that we can be aware of your needs.

Parent/Guardian Name (Primary Household) 

 

 

Medications

 
Please list all medications (including over the counter and non-prescription drugs) taken routinely. On Camp registration day, bring enough medication to last the duration of camp (9 days, Saturday - Sunday). Medication must be in it's original package/bottle that identifies the prescribing physician (if prescribed), the name of the medication, the dosage, and the frequency of administration. If your camper is currently taking medication routinely, DO NOT make any drastic changes in dosage levels or change medications prior to camp send-off.

Parent/Guardian Release Authorization

All teenagers picked up from Remembrance Ranch must be signed out by a staff member. Please list individuals your teen may be released to, including parents and guardians. A positive photo ID may be required.

Your child will only be released to individuals whose names are on this consent form. Any questions regarding this consent can be directed to Remembrance Ranch Office.

General Health History

Sleep-Related Concerns

Mental and Emotional Health

Behavioral or Developmental Concerns

Other Health Concerns

Immunizations

Has your child received the following immunizations?
(Please check all that apply and include approximate dates if known)

Allergies

Describe reaction and management of reaction. If none please typeNA

General Transportation Release 

This document serves as a general transportation release for minor children to be transported by Remembrance Ranch or its authorized representatives for activities and events organized or approved by Remembrance Ranch.

Medical Information Release

In the event of an emergency, Remembrance Ranch is authorized to seek medical attention for the child as deemed necessary. Relevant medical information should be provided to Remembrance Ranch separately if applicable.

Acknowledgment and Waiver

Parents or guardians acknowledge and understand that while reasonable precautions will be taken to ensure the safety of your child, there are inherent risks associated with transportation. Remembrance Ranch and its representatives are not liable for any injuries, accidents, or unforeseen incidents that may occur during transportation, except in cases of gross negligence or willful misconduct.

Please initial below if you agree:

Consent for release of information

Consent for School Visits 

By signing below, I hereby authorize Remembrance Ranch and its employees and agents to make contact with my teenager while on school grounds, during school hours at the school/s listed below. My signature also serves as consent to above mentioned releases as well. 

School Hours

Normal middle school hours are 8am-2:30pm Monday through Friday. The case worker for Remembrance Ranch will be visiting your teen at school every other month. Please let us know if your teen has any days/times that they are not in school during regular school hours.

Signature of Parent/Guardian

 
Type your name in the box below identifying the name of the parent/guardian who completed this application. When you arrive at Camp Registration and Send-Off, you will be asked to sign this entire document on the line below. By signing this document, you are are signifying that all the information you entered is accurate and you are in full agreement. By checking the boxes in this application (to include the sections titled General Liability, Photo Release, Equine Liability Release, Emergency Authorization, and Consent for Release of Information) you are agreeing to the terms identified under each section.

I understand that the Records will be released and received for the purpose of treatment and quality improvement activities. Remembrance Ranch, its employees, officers and medical staff are released from liability for the release of information in accordance with this consent.

Note: This authorization is considered valid for 24 months from the date of signature.  

Sign Here