Health History and Examination Form

Transcription

1 Health History and Examination Form Based on forms developed by American Camp Association, American Academy of Pediatrics Council on Health, & Association of Camp Nurses. Name Last First Middle Unit: Week: (For Camp Use) Birth date / / Age at camp Grade in fall GS level in fall Home address Street address City State Zip Custodial Parent/Guardian Name: Relationship to camper: Day Phone: Business Phone: Cell Phone: HEALTH HISTORY Insurance Information Is the participant covered by family medical/hospital insurance? Yes No If so, indicate carrier or plan name Policy Holder Policy ID # Second Parent/Guardian Name: Relationship to camper: Day Phone: Business Phone: Cell Phone: Additional Emergency Contact (Required! Someone who knows the camper well, and can assist with reaching the guardian.) Name: Relationship to camper: Cell Phone: Alternate Phone: Address: The following information must be filled in by the parent/guardian. The intent of this information is to provide camp health care personnel the background to provide appropriate care. Keep a copy of the completed form for your records. Any changes to this form should be provided to camp health personnel upon participant s arrival in camp. Provide complete information so that the camp can be aware of your needs. Allergies: No known allergies. Relationship to camper Group # This camper is allergic to: Food Medicine Environment (hay fever, insects, etc.) Other (Describe the allergy and the reaction seen.) If a camper has an anaphylactic allergy, include a copy of the camper s allergy action plan. We cannot guarantee that any area at camp is allergen-free. Diet and Nutrition: This camper eats a regular diet. This camper has special food needs. (Describe below.) MEDICATIONS This camper takes NO medications on a routine basis. Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire time at camp. All medications must be given to the health supervisor (including over-the-counter or nonprescription drugs). If your child needs medication while attending camp, medication must be in the original, labeled container. Prescription medication must have the full pharmacy label. Over-the-counter medication must also be in the original container, clearly labeled and marked with the camper s name and dosage instructions. (Attach additional pages for more medications) Name of Medication Amount or Dose How it is given (ex: by mouth) When it is given (specific times or as needed) Date Started Reason for taking #656F 03/17 1 of 4

2 I hereby give permission for the administration of the following medications if deemed necessary by a qualified first aider, nurse or physician. Dosages will be administered according to directions on the container unless otherwise directed by a physician. Please ( ) check any medication your child MAY be given. Acetaminophen Antihistamine/allergy medicine Ibuprofen Throat lozenges/spray Antacid tablets-chewable Anti-itch agent Visine/eye relief drops Fiber enhancer/anti-diarrhea Antibiotic/antiseptic ointment Silvadine/cream for burns Expectorant/cough syrup agent Anti-fungal cream Decongestant Swimmers ear solution Other PARENT/GUARDIAN SIGNATURE: DATE: / / (Signature required if sending/approving any medication.) GENERAL HEALTH HISTORY: Check Yes or No for each statement. Explain Yes answers below. Has/does the camper: Have hypertension? Yes No Have sleep disturbances? Yes No Have recurrent/chronic illness(es)? Yes No Have a current history of bedwetting? Yes No Had a recent injury/illness/infection? Yes No Have musculoskeletal disorders? Yes No Have heart defect/disease? Yes No Had seizures? Yes No Have asthma? Yes No Wear glasses/contacts/protective eyewear? Yes No Have diabetes? Yes No Had fainting or dizziness? Yes No Have hearing Impairment? Yes No Have frequent bloody nose? Yes No Have emotional disturbances? Yes No Have motion sickness? Yes No Have problems with menstruation? Yes No Have problems - constipation, stomach aches? Yes No Had surgery/hospitalization? Yes No Have frequent headaches? Yes No Have frequent ear infections? Yes No Have neuro/neural development disorders? Yes No Please explain any yes answers: To better care for your camper: Provide any additional information about the camper s behavior or physical, mental, emotional, and social health that you think important or that may affect the camper s ability to participate in the camp program (shyness, learning style, etc.) List any strategies used to manage the concern or enhance the camper s ability. Your honest and thorough answers will help our staff better serve the needs of your camper. Attach additional sheet if needed. Family physician Phone Family dentist/orthodontist Phone Restrictions: Camp activities are similar to those described in the newsletter, camp brochure, or information packet. I have reviewed the camp s program/activities and feel the camper can participate without restrictions. I have reviewed the camp s program/activities and feel the camper can participate with the following restrictions or adaptations. (Please describe below and speak with the health supervisor.) Important These boxes must be complete for attendance Parent/Guardian Authorizations: I know of no reason(s) other than the information given on this form why my camper should not participate in the activities noted. If my camper is ill or has been recently exposed to a contagious disease, I understand she will not be permitted to attend camp. I am aware that a statement from a physician (on the last page of this form) must be completed for my child to keep a specific medication/appliance with her. I hereby give my permission for my camper to receive first aid care while attending camp. If it should become necessary for her to receive professional medical, surgical or dental treatment, I authorize camp personnel to give the necessary parental consent in my stead for a licensed physician, surgeon or dentist to administer treatment they deem necessary, including hospitalization and surgery. I understand that EVERY EFFORT will be made to contact me immediately upon discovery of the emergency. I further understand that I will take full financial responsibility for all expenses, which might be incurred, that are not covered by Girl Scout insurance. This consent is given in advance of any specific diagnosis or treatment being required and is given primarily to encourage camp staff who have temporary custody of my camper, and the said physician, surgeon or dentist, to exercise their best judgment in situations deemed an emergency as to the requirements of said diagnosis or medical, surgical or dental treatment. Waiver available upon request if for religious reasons, you are unable to give consent for emergency medical care. Signature of parent/guardian Printed Name I also understand and agree to abide by any restrictions placed on my participation in camp activities. Date Signature of minor camper Date #656F 03/17 2 of 4

3 Unit: Week: (For Camp Use) PHYSICAL EXAM Campers staying 3 (three) or more nights must have a physical exam that has been administered within one year before starting date of activity by either a Physician, a Physician Assistant licensed by a State Board of Physician Assistant Examiners or a Registered Nurse recognized as an Advanced Practice Nurse by the Board of Nurse Examiners. Camper Name: D.O.B.: / / Height: Weight: B.P.: Appearance Nutrition: Eyes -Without glasses: R 20/ L 20/ With glasses: R 20/ L 20/ GENERAL HEALTH Satisfactory Not Satisfactory Not Examined Satisfactory Not Satisfactory Not Examined Ear/Nose Throat Teeth Heart Lungs Abdomen Musculoskeletal Hernia Skin HGB* *Not required for every physical examination. Grade K-6 should have this test if she has not already had it, either when entering school or at any time since. Grade 7-12 should have this test if she has not had it since entering puberty. General physical and emotional health Other notes HISTORY AND IMMUNIZATION RECORD: Please complete and/or attach official immunization record. Which of the following has the participant had? Measles Chicken Pox German Measles Mumps Hepatitis A Hepatitis B Hepatitis C Date of last TB Mantoux Test: Results: Positive Negative Please give all dates of immunization for: Vaccine Dates: Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr DTP TD (tetanus/diphtheria) Tetanus Polio MMR or Measles or Mumps or Rubella Haemophilus influenza B Hepatitis B Varicella (chicken pox) Continued next page #656F 03/17 3 of 4

4 PHYSICAL EXAM (continued) COMMENTS AND RECOMMENDATIONS: The applicant is under the care of a physician for the following conditions Treatment to be continued at camp Medications to be administered at camp (name, dosage, frequency) Any medically-prescribed meal plan or dietary restrictions Known allergies Additional information for health care staff at camp This person is in satisfactory condition and may engage in all usual activities. This person s activities should be modified or restricted in the following manner: This person may carry this specific medication or appliance with her at all times and administer it to herself as she needs it. (For example: inhaler for asthma or medication for bee sting.) Medication: Instructions for use: LICENSED MEDICAL PERSONNEL INFORMATION: (Office stamp or label acceptable, except for signature.) Name of Clinic/Facility: Address: City: State: Zip: Administered by (print name): Phone: ( ) Signature/Title (Ink Only): Date: / / SCREENING RECORD: (FOR CAMP USE ONLY) a.m. Date screened Time p.m. Meds received Updates/additions to health history noted Yes No None required Current health needs identified Observational notes Screened by #656F 03/17 4 of 4

5 RESIDENT CAMP CAMPER S CONFIDENTIAL INFORMATION Camper Name In helping your camper adjust to camp life, we are asking for the following confidential information to be filled out by the camper s parent/guardian and the camper. Your honest and thorough answers will help our staff better serve the needs of your camper. Please use the back of this form if more space is needed for details. Session School attending City Grade (in fall) This will be her year at Resident Camp. How would you describe your camper? (shy, nervous, leader, daydreamer, etc.) Her camp name/nick name is What groups or clubs does she belong to? Hobbies/Interests? How does your camper get along with children her own age? Has your camper been away from home/family two or more consecutive nights successfully? YES NO What do you hope that your camper will gain from her experience at Resident Camp? How was her last camp experience? Does your camper have any specific fears or phobias? (storms, water, dark, insects, etc.) List any restricted activities: Has your camper started her menstrual periods yet? YES NO If no, is she prepared if it happens at camp? YES NO NOT SURE If yes, when did she first start? Are you both comfortable with her using tampons at camp? YES NO Does your camper experience any complications or problems relating to her menstrual periods? (severe cramps, fatigue, etc.) Are there any issues that may make it difficult for her or may affect her camp behavior? (school problems, moving, loss of pet, family problems, Autism, Asperger s, etc.) Please provide any other information, suggestions, and ideas that will help your camper s counselor in fulfilling her duties to make your child s camping experience a more enjoyable one. Three things the camper wants to do most at camp: Girl Scouts of Eastern Oklahoma: /16

6 GIRL SCOUTS OF EASTERN OKLAHOMA TALLCHIEF RESIDENT CAMP CAMPER AGREEMENT CAMPER S NAME: Operated as a residential summer camp, campers are expected to willingly participate with their campmates and counselors in activities and group living as part of the entire camp community. Personal housekeeping and shared camp kapers are included in our commitment to a positive, well-rounded learning experience. The camp experience is created by everyone, for everyone. I understand that my attitude and behavior are critical to the success of my camp experience. Therefore, for the good of the camp as well as my fellow group members, I agree to abide by the following: I agree to abide by the rules established for all campers and to use behavior which is appropriate to Girl Scouts and Girl Scout Resident Camp. I will use appropriate language and will only discuss appropriate topics in any public or private conversations I have with other campers or staff. I agree to do my part of the daily responsibilities, such as food preparation, setting up camp, and cleaning up after myself and others. I agree to willingly participate with my campmates and counselors in program activities and group living as a part of the entire camp community. I understand that the use or possession of personal firearms, tobacco, alcohol, or illegal drugs will not be tolerated. Any violation of this rule will result in immediate expulsion from camp. I understand that Camp Tallchief adheres to a no tolerance policy regarding physical, verbal, or emotional abuse of campers and staff. I further understand that if I am involved in any situation where I am physically, verbally, or emotionally abusive to another camper or camp staff, that I will immediately be sent home from camp. I understand that Camp Tallchief has a strict policy on the possession of electronics at camp. I agree to not possess ANY electronic device during my stay at camp. This includes cell phones, MP3 players, video games, personal tablets, laptops, GPSs, radios, and music players. I further understand that such devices found in my possession will be taken from me and returned to my parent or guardian at the end of my camp session. I have read and understand the statement regarding vehicles in Welcome to Camp Tallchief. I understand that no personal sports equipment, pets, or animals are allowed on camp property AT ANY TIME. Exceptions are stated in Welcome to Camp Tallchief. I agree to abide by the Girl Scout Promise: (On my honor, I will try to serve God and my country, to help people at all times, and to live by the Girl Scout Law.), and the Girl Scout Law: (I will do my best to be honest and fair, friendly and helpful, considerate and caring, courageous and strong, and responsible for what I say and do, and to respect myself and others, respect authority, use resources wisely, make the world a better place, and be a sister to every Girl Scout.). I understand that if I am sent home early because of any serious misconduct, it will be at my parent s/guardian s expense and no refund will be awarded. CAMPER S SIGNATURE DATED PARENT/GUARDIAN AGREEMENT I respect my camper s decision to be involved with Girl Scouts and will do the best I can to ensure that she is properly prepared to attend camp. I will allow her to make age appropriate decisions regarding her preparations to attend camp. I understand and agree with all of the above responsibilities of my camper. I also agree to abide by the principles stated in the Girl Scout Promise and Law. I understand that if my camper is sent home early because of any serious misconduct, it will be at my expense and no refund will be awarded. PARENT/GUARDIAN S SIGNATURE DATED 12/16 PLEASE COMPLETE PHOTO RELEASE ON BACK SIDE

7 PUBLICITY RELEASE FOR MINORS I, being Parent or Guardian of ("My Child"), hereby GIVE MY CONSENT DO NOT GIVE MY CONSENT that the photographs, video-tapes, motion picture film, and/or electronic images for which she posed or which are taken as a result of her participation in Girl Scout Resident Camp, with or without her knowledge, and/or audio recordings made of her voice may be used by Girl Scouts of Eastern Oklahoma, an Oklahoma corporation ("Council"), its employees, agents, and representatives, and others authorized by the Council ("Indemnitees") in whatever way they may desire, including television. I consent that any such photographs, films, recordings, electronic images and the negatives/plates, film, or other media upon or from which they were made or produced shall be their property, and they shall have the right to duplicate, reproduce and make other such use of said photographs, video-tapes, motion picture film, and/or electronic images and/or audio recordings as they may desire, without any claim on the part of My Child or on my part. I will defend, indemnify, and hold the Indemnitees and each of them harmless from all liability, damage, loss, and claims arising from or in any way associated with the use by the Indemnitees, or any of them, of the photographs, video-tapes, motion picture film, and/or electronic images and/or audio recordings of My Child as described above. PARENT/GUARDIAN S SIGNATURE DATED

8 GIRL SCOUTS OF EASTERN OKLAHOMA CAMP TALLCHIEF NO CELL PHONE AND VIDEO VOYEURISM POLICY Dear Parents/Guardians, We take the safety and well-being of our campers your children very seriously. After all, giving your children over to the care of other people is perhaps the greatest act of trust you, as a parent, can engage in. We aim to do everything we can to earn and keep that trust. We also know that we cannot do this without your help. We appeal to you, as parents, to partner with us to ensure that your children continue to have the safest, most wholesome experience with us at camp as possible. Cell Phones Camp Tallchief operates under a no cell phone policy. Aside from the fact that cell phones are expensive and can get lost or stolen, there is a fundamental problem with campers having cell phones at camp and that is TRUST. When your children come to camp, you are both making a leap of faith, temporarily transferring their primary care from you as their parents, to us and their counselors. This is one of the growth-producing, yet challenging aspects of camp. As children learn to trust other caring adults, they grow and learn, little by little, to solve some of their own challenges. We believe this emerging independence is one of the greatest benefits of camp. It is one important way your child develops greater resilience. Contacting you, by using a cell phone which you have given them, essentially means they have not made this transition. It prevents us from getting to problems that may arise and addressing them quickly. Sending a cell phone to camp is like saying to your child that you as the parent haven t truly come to peace with the notion of them being away from you and in our care. We agree to tell you if your child is experiencing a challenge in their adjustment to camp. You can help by talking with your child and let them know there is always someone they can reach out to, whether it is a trusted activity leader, counselor, camp health supervisor, or the camp director. We are all here to help, but if you don t trust us, your children certainly won t! If your camper is found with a cell phone, it will be confiscated and held until you check her out from camp. Digital Photographs/Recordings Another drawback of having cell phones at camp is that many of them have built-in cameras. It has happened at some camps around the country that children have secretly taken photographs of other campers or staff during inappropriate times and displayed them publicly. We do not ban digital cameras but we do not recommend bringing them to camp. The Video Voyeurism Prevention Act of 2004 defines video voyeurism as capturing an image of a private area of an individual without their consent, and knowingly doing so under circumstances in which the individual has a reasonable expectation of privacy. All 50 states have now enacted video voyeurism laws. Oklahoma s Peeping Tom law rates the offense as a FELONY. You should know that any camper or staff member who takes a compromising photograph of another camper or staff member and makes it public in any way, may be subject to dismissal from camp, or may not be allowed to return to camp. If the law is broken, the appropriate authorities will be notified. (This includes websites like, but not limited to, youtube.com, myspace.com, and facebook.com.) Working Together to Keep Your Children Safe We see many positive, exciting ways for children to enjoy the healthy benefits of the Internet and other technological advances. As advocates for children, we want to work with you to keep those experiences safe, healthy, and positive for everyone. That is why we have taken the time to write these policies and urge you to talk with your children about the importance of these issues. As always, feel free to speak with the camp staff if you have concerns with regard to any of this information CAMPER NAME: As the parent/guardian of the above-named camper, I am aware of the No Cell Phone policy at Camp Tallchief and I have shared the policy with my camper. My signature below indicates that my camper and I both agree to comply with the policy. Parent/Guardian Signature Date