Camper Confirmation Packet 2015 Email: campadmin@wa.easterseals.com Overview Welcome to the 2015 Season at Easter Seals Camp Stand by Me! This packet includes important paperwork that we need on file here at camp in order for your camper to attend. This packet must be returned 30 days prior to camp and is good for one calendar year. This packet contains the following items. Please check them off and return them as a packet either by mail, email or fax. Physical Examination - All campers must have a physical less than 12 months before attending camp. Please schedule an appointment with your doctor as soon as possible. Camp Medication List-- This form should include all medication that your camper needs to take while at camp. Please make sure this list includes any herbal supplements or over-the-counter medications that your camper will be taking while at camp. No medication will be passed without a doctor s signature. If there is a medication change between the time the Physical Exam is submitted and the date of your session, please ask your doctor to fax an updated medication list to our office at 253-590-0594. *Please read the note about medication below. Health History Form A parent or guardian who is knowledgeable about the camper s medical history should complete this form. Waivers Please read, sign and date. Proof of Insurance We maintain a copy of all campers insurance or Medicare/Medicaid cards in case of emergency while at camp. If there have been any changes to your insurance information since your last camp session, please send a copy of your insurance card with your health forms. If this is your first time attending Camp Stand by Me, please send a copy of your insurance card with your health forms. *A note about medication: The camp nurse will check-in all medications and review the medication list provided by your doctor. Please ensure that medication is easily accessible in a separate bag or on top of the suitcase to expedite the check-in process. Our medical staff will only dispense medications, including herbal remedies or vitamins, according to a physician s written instructions. You MUST present medications in their original prescription packaging at camp check-in. PLEASE DO NOT PRE-PACKAGE MEDICATION UNLESS YOU HAVE HAD IT PACKAGED AT A PHARMACY. Please bring a note from your doctor if the medication dosage is different than that listed on the bottle and/or on the back of the Physical Exam form. Easter Seals Camp Stand by Me has many commonly used over-the-counter medications which our nurse will dispense as needed. These include acetaminophen, ibuprofen, antacids, and similar items. Unless your camper uses such medication on a daily basis, you will not need to send these items to camp.
Physical Examination Camper Name: Date of Appointment: This form is to be completed by a licensed physician, nurse practitioner or physician s assistant. The medical examination must be completed within 12 months of participation in all Easter Seals Camping and Respite programs. Easter Seals must receive this form 30 days prior to the start of the participant s assigned session. Please provide a complete list of medications INCLUDING HERBAL AND OVER THE COUNTER MEDICATIONS to be taken at camp on the back of this page. Height Weight Temp EENT Lungs Pulse Heart Abdomen Resp. GU Blood Press. State the approximate date of occurrence or most recent incident: Chicken pox Mumps Diabetes Ear infections Rheumatic Fever Asthma Measles Rescue inhaler Hepatitis carrier Seizures Migraines Shunt Sunburn-prone Other: Allergies Latex Food allergy Insect stings Penicillin Other: If the applicant has an allergy, what reaction(s) does he/she have? Does this person have a positive diagnostic x-ray for an Atlantoaxial Dislocation Condition? Yes No The applicant is under the care of a physician for the following medical diagnosis/disability; describe any operations or serious illnesses that relates to participant s condition or care: Vaccinations: Current on all childhood vaccinations except: Hepatitis B series Date of most recent Tetanus vaccine TB Test Date read: Positive Negative Recommendations and Restrictions for Easter Seals Recreational Programs In my opinion, the above conditions do do not preclude the applicant s participation in an active recreational program. There are medical reasons for limiting or restricting swimming, horseback riding, boating or other outdoor activities such as walking on rough terrain, participation in active sports or sleeping in tents: Yes No Limitations: Treatments and diets that are to be continued while participating in Easter Seals programs: I have examined the person herein described and reviewed his/her health history. It is my opinion that he/she is physically able to engage in any required activities, except as may be noted above, and is free of communicable or contagious disease. Signature of licensed practitioner: Date: Printed name: Phone #:
Camp Medication List Please provide a complete list of ALL medications taken by this patient INCLUDING OVER THE COUNTER, HERBAL REMEDIES and FORMULA as well as any other prescribed dietary supplements. No medication will be dispensed to campers without the signature of a licensed practitioner. If the camper takes no medication, please indicate that in the first medication space. Name of patient: Medication Dosage (i.e. 500 mg) **please note this is the dosage of an individual tab or capsule. Quantity Given (i.e. 2 tabs) Times Given Camp medication passes are at 8:00 AM, 12:00, 2:00, 5:30, and 8:00 PM I have reviewed the above medication and direct that they be provided to the above named camper as described. Signature of licensed practitioner: Date: Printed name: Phone #:
Health History Camper Name: Camp Session: List any illnesses this camper has had within the last year: List any occurrences of hospitalization or medical treatment within the last year: Has the camper had any previous illnesses or injuries that we should be aware of during their time at camp? Does the camper have any infectious diseases including blood-borne diseases (i.e. Hepatitis or HIV)? Yes No Please explain: Does the camper use any breathing aids, machines, or treatments: Yes No Please explain: Does the camper wear: glasses contacts hearing aides dentures AFOs/Braces If so, please describe: Camper takes medication whole with juice/water whole in applesauce crushed in applesauce crushed in g-tube other Does the camper take medication willingly? Yes No If the camper is non-verbal or doesn t communicate needs clearly, please list any common indications that the camper isn t feeling well or is in pain: If your camper needs medical treatment that is not available on-site, we will attempt to contact you prior to taking them to the doctor unless it is an emergency. In the case of an emergency, you will be contacted as soon as emergency procedures have been followed. Authorization for medical treatment: I hereby give permission to the camp to provide routine health care, administer prescribed medications, and seek emergency medical treatment including ordering x-rays or routine tests for the above named camper. I agree to the release of any records necessary for insurance purposes. I give permission to the camp to arrange necessary related transportation. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person named above. Signature of parent/guardian/independent adult camper Printed name Date Best phone number for questions
2015 Confirmation Packet Clothing and Adaptive Equipment Packing List Please fill out the following clothing and adaptive equipment packing list as you pack your camper s clothing and equipment. The number of items needed will vary depending upon the needs of your camper and the dates of your camp sessions. The camp staff will do its best to make sure that the camper arrives and leaves with all of their appropriate camp items. Please understand that items are occasionally lost, broken, or accidentally sent home with another camper. PLEASE DO NOT SEND EXPENSIVE ITEMS SUCH AS IPODS, GAMEBOYS, OR OTHER ELECTRONICS TO CAMP. CELL PHONES ARE NOT PERMITTED AT CAMP. Please bring this form with you to camp. NOTE: All items MUST be permanently labeled with camper s name (no initials, please). Clear labeling helps ensure items will come home at the end of the session Date: / / Session #: Cabin #: Camper Name Staff Initials / IN OUT List # Items Description of Items Shirts Pants and Shorts Jacket, Sweater and Sweatshirts Underclothes Socks (Pairs) Swimsuit Pajamas Bedding and Pillow **we recommend sheets/blankets for campers who are incontinent at night Towels and Washcloths Toiletries/Personal Hygiene Articles Adaptive Equipment Other (Camera, flashlight, etc.)