YC19: Camper Health Form

The following information is required to ensure that your child's individual needs are met while they are at camp. The information is confidential and will be made available only to those adults who are directly responsible for your child's care.

1. PARENT/GUARDIAN INFORMATION:
*First Name
*Last Name
*Address 1
*City
*State
*Zip
*Phone
*Email
*Camper's First and Last Name:
*Camper's Date of Birth:
*Gender:
Male
Female
*a) Parent/Guardian with legal custody to be contacted in case of illness or injury:
*Parent/Guardian's Phone number:

Please include area code

*Relationship to Camper:
b) Second Parent/Guardian with legal custody to be contacted in case of illness or injury:
Second Parent/Guardian's Phone number:

Please include area code

Relationship to Camper:
c) Additional Contact in event parents/guardians cannot be reached:
Contact's Phone number:

Please include area code

Relationship to camper:
2. ALLERGIES:
*Any known allergies?:
Yes
No
My child is allergic to:
Food
Medicine
Environment (insect stings, hay fever, etc.)
Other
Please describe below what your child is allergic to, and the reaction seen.
3. DIET, NUTRITION:
*My child eats a regular diet.
Yes
No
*My child eats a regular vegetarian diet.
Yes
No
*My child has special food needs.
Yes
No
Please describe special food needs below.
*RESTRICTIONS:
I have reviewed the program and activities of the camp and feel my child can participate WITHOUT restrictions.
I have reviewed the program and activities of the camp and feel my child can participate WITH the following restrictions or adaptions.
Please describe the restrictions below.
4. MEDICAL INSURANCE INFORMATION:
*My child is covered by family medical/hospital insurance:
Yes
No
Insurance Company:
Policy number:
Subscriber:
Insurance company phone number:

Please include area code

Name of your child's primary doctor and phone number:

Please include area code

Name of dentist/orthodontist, and phone numbers:

Please include area code

5. IMMUNIZATION HISTORY:

Please provide us dates of first completed and most recent booster shots.

Diptheria, Tetanus, Pertussis * (DTaP) or (TdaP)
Tetanus booster * (dT) or (TdaP)
Mumps, measles, rubella * (MMR)
Polio * (IPV)
Haemophilus influenza type B (HIB)
Pneumococcal (PCV)
Hepatitis B
Hepatitis A
Varicella (Chicken Pox)
Meningococcal meningitis (MCV4)
*Tuberculosis (TB) test
Negative
Positive
Has not had a TB test
Date of Tuberculosis test:
Parent/Guardian:

By checking this box I acknowledge that my child has NOT been fully immunized, I understand and accept the risks to my child from not being fully immunized.

6. MEDICATION:

“Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Please review camp instructions about required packaging/containers. Many states require original pharmacy containers with labels which show the camper’s name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp. ALL MEDICINE THAT IS OUTDATED WILL NOT BE ACCEPTED.

 

 

*Will your child be taking any daily medications while at camp?
Yes
No
Name of MEDICATION(s), DATE STARTED, REASON FOR TAKING, DOSE GIVEN, HOW IT IS GIVEN.
When is medication to be given?:
Breakfast
Lunch
Dinner
Bedtime
Other
Please specify:
Non-prescription medications:

The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Put a
check next to those the camper should NOT be given.

 

Acetaminophen (Tylenol)
Phenylephrine decongestant (Sudafed PE)
Antihistamine/allergy medicine
Diphenhydramine antihistamine/allergy medicine (Benadryl)
Sore throat spray
Calamine lotion
Laxatives for constipation (Ex-Lax)
Ibuprofen (Advil, Motrin)
Pseudoephedrine decongestant (Sudafed)
Guaifenesin cough syrup (Robitussin)
Dextromethorphan cough syrup (Rubitussin DM)
Generic cough drops
Antibotic cream
Aloe
Pepto Bismol for Diarrhea
7. HEALTH HISTORY:

Check "YES" or "NO" for each statement. If "YES", please explain by putting the # of statement and explanation below.
Has/does your child:

*1. Been hospitalized?
Yes
No
Please explain:
*2. Had surgery?
Yes
No
Please explain:
*3. Recurrent/chronic illnesses?
Yes
No
Please explain:
*4. Recent infectious disease?
Yes
No
Please explain:
*5. Recent injury?
Yes
No
Please explain:
*6. Asthma/wheezing/shortness of breath?
Yes
No
Please explain:
*7. Diabetes?
Yes
No
Please explain:
*8. Seizures?
Yes
No
Please explain:
*9. Headaches?
Yes
No
Please explain:
*10. Wear glasses, contacts or protective eye wear?
Yes
No
Please explain:
*11. Dizziness or fainting?
Yes
No
Please explain:
*12. Passed out/had chest pain during exercise?
Yes
No
Please explain:
*13. Had mono within the past 12 months?
Yes
No
Please explain:
*14. Female: have problems with periods/menstruation?
Yes
No
Please explain:
*15. Problems with sleeping or falling asleep?
Yes
No
Please explain:
*16. Back or joint problems?
Yes
No
Please explain:
*17. History of bed wetting?
Yes
No
Please explain:
*18. Problems with diarrhea/constipation?
Yes
No
Please explain:
*19. Skin problems?
Yes
No
Please explain:
*20. Traveled outside the country in the past 9 months?
Yes
No
Please name the country and dates traveled.
8. MENTAL, EMOTIONAL AND SOCIAL HEALTH:

Check "YES" or "NO" for each statement. If "YES", please explain by putting the # of statement and explanation below.
Has your child:

*1. Ever been treated for Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD)?
Yes
No
Please explain:
*2. Ever been treated for emotional or behavioral difficulties or an eating disorder?
Yes
No
Please explain:
*3. During the past 12 months seen a professional to address mental/emotional health concerns?
Yes
No
*4. Had a significant life event that continues to affect your child's life?

(History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, other)
 

Yes
No
Please explain:
Additional information:

Please provide any additional information about your child's health that may be important or may affect your child's ability to participate in the camp program.

Parent/Guardian Authorization for health care:

By checking this box, I the parent acknowledge and agree the following on this health form is correct and accurately reflects the health status of the camper to who 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 hospitalize, 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.
If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance.

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