PARENT / GUARDIAN: PLEASE FILL OUT AND SIGN THIS PAGE.

Transcription

1 CAMPER HEALTH Attending: 1st Session 2nd Session (Circle one) HISTORY FORM 2015 Camper Name: Developed and reviewed by: American Camp Association, First Middle American Academy of Pediatrics Council on School Health & Male Female Birth Date Association of Camp Nurses Month/Day/Year Please Return by May 15, 2015 to: Parents: Please fill out pages 1 and 3, sign and give to your P.O. Box 625 Saddle River, NJ child's doctor to complete pages 2 and 4. Fax: / michele@kencamp.com Parent and doctor signatures are required. After May 15th please mail to: Please send (with appropriate paperwork) to our office when complete. P.O. Box 548 Kent, CT PLEASE KEEP A COPY FOR YOUR RECORDS. Fax: / michele@kencamp.com Camper Home Address: Street City State Zip Parent/Guardian with legal custody to be contacted in case of illness or injury: Name: Relationship to Camper: Preferred Phone: Home Address: (If different from above) Street City State Zip Second parent/guardian or other emergency contact: Name: Additional contact in the event parent(s)/guardian(s) can not be reached: Relationship to Camper: Preferred Phone: Name: Relationship to Camper: Preferred Phone: Allergies: No Known Allergies This camper is allergic to Circle all that apply below Food Medicine The Environment (insect stings, hay fever, etc) Other (Please describe below what the camper is allergic to and the reaction seen.) Diet, Nutrition: This camper eats a regular diet This camper eats a regular vegetarian diet This camper has special dietary needs (Please describe below.) Restrictions: I have reviewed the program and activities of the camp and feel the camper can participate without restrictions. I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations (Please describe below). Medical Insurance Information: This camper is covered by family medical/hospital insurance: Yes No If yes, please provide copy of Insurance Card (Front and Back), thank you. Parent/Guardian Authorization for Health Center This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitilize, secure proper treatment for and order injection, anesthesia or surgery for this child. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child's health record from providers who treat my child and these providers may talk with the program's staff about my child's health status. Signature of Custodial Parent/Guardian Date: Relationship to Camper: If for religious reasons, you can not sign this, contact the camp for a legal w aiver w hich must be signed for attendance. Pg 1/6 PARENT / GUARDIAN: PLEASE FILL OUT AND SIGN THIS PAGE.

2 CAMPER HEALTH HISTORY FORM 2015 Camper Name: Developed and reviewed by: American Camp Association, First Middle American Academy of Pediatrics Council on School Health & Birth Date: Association of Camp Nurses Immunization History: Provide the month and year for each immunization. Starred (*) immunizations must be current. Copies of immunization forms from health-care providers or state or local government are acceptable; please attach to this form. Immunization Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Most Recent Dose Month/Year Month/Year Month/Year Month/Year Month/Year Month/Year Diptheria, tetanus, pertussis* (DTaP) or (TdaP) Tetanus booster * (dt) or (TdaP) Mumps, measles, rubella* (MMR) Polio* (IPV) Haemophilus influenzae type B (HIB) Pneumococcal (PCV) Hepatitis B Hepatitis A Varicella Had Chicken Pox (chicken pox) Date: Meningococcal meningitis (MCV4) Tuberculosis (TB) test - if risk factors present: Date: Negative Positive Circle One If your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being fully immunized. Signature of Custodial Parent/Guardian: Date: Relationship to Camper: Medication: This camper will not take any daily medications/vitamins/supplements while attending camp. This camper will take the following daily medications/vitamins/supplements while at camp: "Medication is any substance a person takes to maintain and/or improve their health." This includes vitamins & natural remedies. All medications/supplements/vitamins must be ordered via CampMeds. Name of Medication Date Started Reason for Taking it When it is given Amount or dose given How it is given Breakfast Lunch Dinner Bedtime Other Time Breakfast Lunch Dinner Bedtime Other Time Breakfast Lunch Dinner Bedtime Other Time The following non- prescription medications are commonly stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Medical Personnel/Parents: Cross out those items the camper should NOT be given. Acetaminophen (Tylenol) Guaifenesin cough syrup (Robitussin) Aloe Hydrocortisone 1% Cream Antacids Ibuprofen (Advil/Motrin) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Laxatives, Citrate of Magnesium Calamine Lotion Lice shampoo or cream (Nix or Elimite) Chloraseptic (Sore throat spray) Milk of Magnesia Loratadine Miralax Muscle rub Dramamine Clotrimazole Cream Pseudoephedrine decongestant (Sudafed) Diphenhydramine antihistamine/allergy medicine (Benadryl) Topical Antibiotic Cream Bacitracin Generic cough drops Copyright 2008 by American Camp Association, Inc. Page 2/6 Rev. 1/2007 LEE/EAW CHILD'S DOCTOR TO FILL IN IMMUNIZATION HISTORY OR ATTACH COPY OF RECORDS. If applicable, CHILD'S DOCTOR TO COMPLETE BOTTOM PORTION FOR ANY MEDICATION TAKEN AT CAMP AS WELL AS THE STATE OF CT MEDICAL AUTHORIZATION FORM (last page of this document)

3 CAMPER HEALTH Camper Name: HISTORY FORM 2015 First Middle Developed and reviewed by: American Camp Association, Birth Date: American Academy of Pediatrics Council on School Health & Association of Camp Nurses General Health History: Check "Yes" or "No" for each statement. Explain "Yes" answers below. Has/does the camper? 1. Ever been hospitalized?.... Yes No 12. Passed out/had chest pain during exercise?.... Yes No 2. Ever had surgery? Yes No 13. Had mononucleosis ("mono") during the past 12 months? Yes No 3. Have recurrent/chronic illnesses?... Yes No 14. If female, have problems with periods/menstruation? Yes No 4. Had a recent infectious disease?. Yes No 15. Have problems with falling asleep/sleepwalking?.. Yes No 5. Had a recent injury? Yes No 16. Ever had back/joint problems? Yes No 6. Had asthma/wheezing/shortness of breath? Yes No 17. Have a history of bedwetting?.. Yes No 7. Have diabetes? Yes No 18. Have problems with diarrhea/constipation? Yes No 8. Had seizures?. Yes No 19. Have any skin problems?.. Yes No 9. Had headaches?. Yes No 20. Traveled outside the country in the past 9 months?. Yes No 10. Wear glasses, contacts or protective eyew ear? Yes No 21. Have history of Lyme Disease Yes No 11. Had fainting or dizziness?.. Yes No Please explain "Yes" answers in the space below, noting the number of the questions. For travel outside the country, please name the countries visited and dates of travel. Mental, Emotional and Social Health: Check "Yes" or "No' for each statement. Has the camper: 1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD)?.. Yes No 2. Ever been treated for emotional or behavioral difficulties (including anxiety or depression) or an eating disorder? Yes No 3. During the past 12 months, seen a professional to address mental/emotional health concerns (including anxiety or depression)? Yes No 4. Had a significant life event that continues to affect the camper's life?.. Yes No (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others) Please explain "Yes" answers in the space below, noting the number of the questions. The camp may contact you for additional information. Health-Care Providers: Name of camper's primary doctor(s): Name of dentist(s): Name of orthodontist(s): Phone: Phone: Phone: What have we forgotton to ask? Please provide in the space below any additional information about the camper's health that you think important or that may affect the camper's ability to fully participate in the camp program. Attach additional information if needed. Copyright 2008 by American Camp Association, Inc. Page 3/6 Rev. 1/2007 LEE/EAW PARENT / GUARDIAN: PLEASE COMPLETE THIS PAGE

4 Camper Health History Form 2015 Camper Name: First Middle Child's Doctor: Please fill out all information on this page. A copy of the Physical Exam Records can be attached. Doctor's signature is required below. Doctor's Office: Please attached physical exam records or fill in below: Physical Exam done Today: Yes No (If "No", date of last physical: ) Month / Day / Year NOTE DATES BELOW FOR YOUR SESSION: ACA Accreditation standards specify physical exam to be dated June 26, 2014 or later for st Session ACA Accreditation standards specify physical exam to be dated July 26, 2014 or later for nd Session Weight lbs Height: Blood Pressure / Allergies: No Known Allergies To foods (list): To medications (list): To the environment (list): Other Allergies (list): Describe Previous Reactions: Diet, Nutrition: Eats a regular diet Has a medically prescribed meal plan or dietary restrictions (describe below): The camper is undergoing treatment at this time for the following conditions: (describe below): None Medication: No daily medications/vitamins Will take the following medications / vitamins while at camp (name, dose, frequency-describe below) Other treatments/therapies to be continued at camp: (describe below) None Needed Do you feel that the camper will require limitations or restrictions to activity while at camp? No Yes If you answered "Yes" to the question above, what do you recommend? (describe below-attach additonal information if needed) I have reviewed the CAMPER HEALTH HISTORY FORM and have discussed the camp program with the camper's parent(s)/guardian(s). It is my opinion that the camper is physically and emotionally fit to participate in an active camp program (except as noted above). Name of licensed provider (please print): Signature: Title: Office Address: Street City State Zip Telephone: Date: Copyright 2008 by American Camp Association, Inc. Page 4 /6 Rev. 2/07 LEE/EAW CHILD'S DOCTOR TO COMPLETE AND SIGN THIS PAGE.

5 Camper Parents, If your child will be taking ANY type of medication on a daily/frequent basis at camp, PRESCRIPTION, OVER THE COUNTER, VITAMINS, SUPPLEMENTS ETC., please note the following next steps: 1) Please register your child with CampMeds at a. All medication must be sent to camp via this service and are not allowed to be brought on the buses on Arrival Day, no exceptions*. CampMeds organizes and pre-doses all medications which allows our nurses to have more time to take care of your children. This service is paid for by KenMont and KenWood Camps. Online registration begins February 20 th. i. Please understand that the State of CT mandates that we do not receive your child s medication(s) directly from you. We can no longer accept meds at the various bus pickups on arrival day or within your child s luggage. Not following this important step with regard to us receiving medication does not only create issues onsite with our nurses but it also does not follow protocol within the State of CT and can result in serious error. We greatly appreciate your understanding of the importance in how we receive your child s meds at camp. *Children carrying epipens and inhalers may carry one with them on the bus if you are sending more than one, you must go through Camp Meds. 2) Please fill out the next page (page 6) State of CT Medical Authorization Form for each medication that your child will be taking while at camp. Note, this form is required per Connecticut State Law and our nurses are not able to dispense any medication without the signed form. In addition, your signature as well as your child s doctor s signature are both required for each form filled out. Please refer to pages 10 and 27 of the Parent Guide for further details. Thank you for your cooperation with this matter. If you have any questions, please do not hesitate to contact us. Tom and Scott Directors pg 5/6

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