Health Forms

Northfork Farms & Outback, LLC

Date Signed *

Authorized Persons Address (If Different From Above)

I hereby give permission to Northfork Farms & Outback, LLC, which is licensed by the State of Michigan, to provide routine, nonsurgical medical care, and to secure emergency medical and surgical treatment., for the camper named above, while attending camp. Note: In accordance with MCLA Act 116 of the public Acts of 1973, as amended, and the rules for licensing camps, this authorization must be signed by a parent or guardian of a child camper unless there is religious objection. *

Camper Name: *

Is child up to date on all shots? *

Yes

Date Signed *

Authorized Person Phone (If Different From Above)

List any medications camper takes (Name, Frequency, and Dose): *

Camper Date of Birth *

Parent/Guardian Phone *

Date Signed *

Address, City, State, Zip *

Please list any dietary restrictions *

Should camp’s activity be restricted because of any physical reason? *

Yes

Additional Explanation:

List any health, behavioral or emotional problems camper has including current infectious disease: *

Parent/Guardian Email *

Check here to receive email updates

I certify that this information is true to the best of my knowledge *

I (parent/guardian) give permission and consent for (camper) to allow photographs to be taken during camp session activities. I further give permission and consent that any such photographs may be published and used by Northfork Farms & Outback, LLC and its agents to illustrate and promote camp experience and camp programs. *

Camper Sex *

Male

Female

Other

Please complete all sections and a separate form for each camper.

If a section is not applicable please place "NA" in the respective box.

The required Riding Release can be completed here.

Authorized Persons Name *

List any special conditions such as bed wetting, fainting, sleep walking, or allergies camper has: *

3637 Morrice Rd, Webberville, MI 48892

517-881-9142 | christie@northforkoutback.com

​​​​​​​​3637 Morrice Rd, ​Webberville, MI 48892 ​

517-881-9142 | christie@northforkoutback.com

3637 Morrice Rd, Webberville, MI 48892