Be WISE DAY CAMP PERSONAL HEALTH AND MEDICAL SUMMARY

Transcription

1 Be WISE DAY CAMP PERSONAL HEALTH AND MEDICAL SUMMARY The purpose of this form is to enable parents and guardians to authorize emergency treatment for children who become ill or injured while under the Be Wise Camp authority, when parents or guardians cannot be reached. Please be sure to complete each blank. Camper Name: (Last Name, First Name) Student Address: (Street, City, State, Zip) Primary Emergency Phone: (This number will be called first in the event of an emergency) Grade Level in the fall: Date of Birth: PARENT OR LEGAL GUARDIAN CONTACTS: Mother/Legal Guardian: *Cell Phone: Work Phone: *Mother s Address : Mother s Address: (only if different from student) Father/Legal Guardian: *Cell Phone: Work Phone: *Father s Address : Father s Address: (only if different from student) IF PARENTS ARE DIVORCED OR SEPARATED: Who has legal (court appointed) custody? Is there a legal restraining order in effect? Yes No If yes, the restraining order is against whom? (circle one) _ Check below any CURRENT health conditions that may require attention during the week at camp: Allergies (be specific) (circle one) Concussion(s)/head injury date(s) Food EpiPen? Yes No Seizure Disorder Insect Stings EpiPen? Yes No Currently on medication for seizures? Yes No Medications or Other (list) EpiPen? Yes No Asthma or other Respiratory Condition(describe) Has an emergency inhaler (circle one) Yes No The inhaler will be at camp (circle one) Yes No (circle one) Physical Disability or Mobility Limitations List/describe ADD ADHD Social / Emotional / Behavioral concerns List/describe Cancer (specific) Treatment / Surgery dates Diabetes Heart Condition (specific) Hearing Problems Hearing Aids Other / describe Vision Problems Glasses or contacts Other / describe Any current restrictions? (circle one) Yes No Please list restrictions: Surgeries: Be Wise EMA PLEASE COMPLETE SIDE TWO AND SIGN

2 Medications taken on a routine basis (include name, dosage, time of day med is taken): Other health information the camp should be aware of: TO GRANT CONSENT In the event reasonable attempts to contact me have been unsuccessful, I DO hereby give my consent for: 1) EMS transportation of my child to any reasonably accessible hospital: 2) the administration of emergency treatment deemed necessary by licensed emergency physicians or licensed emergency medical first responders. This authorization does not cover major surgery unless the medical opinions of two other physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. Current Date Parent or Guardian Signature CAMPERS ARE EXPECTED TO PROIDE THEIR OWN MEDICAL INSURANCE. Denison University does not assume direct responsibility for health care of those who are using the facilities of the university for summer programs. A registered camp nurse is on call 24 hours a day. In the event of injury or illness, campers will be transported to Licking Memorial Urgent care in Granville, Ohio and emergency care treatment to Licking Memorial Health System, Newark, Ohio. Student is covered by Identification number (Date) (Parent or Guardian Signature) MAIL FORM BY JUNE 20 TH TO: Pickerington, OH Be Wise EMA

3 Be WISE Day Camp WEBSITE/DVD PERMISSION SLIP In January 2005, Be WISE Camp established its own website. Through this website, information about camp is disseminated faster than using other forms of communication. Questions about camp are answered rapidly for campers and prospective campers alike. In June, 2007, we produced our first camp DVD. Pictures of campers doing various activities can be found on both the website and DVD. None of the girls are identified. The staff of Be WISE Camp would like to continue producing the website and the camp DVD. In order for us to do so, we need parents to sign the permission slip below. Please tear off the slip, sign it, and send it to by June 20 th. Thank you. WEBSITE/DVD PERMISSION SLIP (Camper Name) I have read the material above and I give permission for to be included in photographs to be used on the Be WISE Camp website and DVD. I have read the material above and I do NOT give permission for to be included in photographs to be used on the Be WISE Camp website and DVD. (Parent/Guardian Signature) Parent address: Send slip by June 20 to: Pickerington, Ohio 43147

4 Be WISE Day Camp Denison Transport Permission Slip Transportation notice: During day camp girls will be transported in vans by Denison University to the swimming pool. In Emergency situations, such as severe weather or medical needs, your camper could be transported by a Be WISE staff member or by Denison University. Our insurance dictates that in order for us to transport your camper as stated above, we need parents to sign the permission slip below. Please tear off the slip, sign it, and either send to bewisecamp@outlook.com or mail to by June 20 th. Thank you. ******************************************************************************** (Camper Name) I have read the material above and I give permission for to be transported as stated above. I have read the material above and I do NOT give permission for to be transported as stated above. (Parent/Guardian Signature) Send slip by mail or electronically by JUNE 20 to: Pickerington, OH 43147

5 Be WISE DAY CAMPER CHECK OUT PROCEDURE For the security of your child, we will be asking to see your driver s license when picking up your daughter. If you are carpooling or if someone else is picking up your daughter, we need to know who your child will be riding with each day. We will be asking to see the driver s license of the person you state will be picking up your daughter. Please fill out the information below and give to Jo Ann on the first day of camp. ************************************************************************* (Camper s Name) I will not be picking up my daughter each day. In the chart below, I have listed each day who will be driving my daughter home. I have also listed the other girls that will be riding in that vehicle with my daughter. Date Driver Girl Girl Girl Girl Girl Girl Tuesday Wednesday Thursday (Parent Signature)