2015 camper health form v2 -...

CAMPER HEALTH Attending: 1st Session 2nd Session (Circle one)

HISTORY FORM 2015 Camper Name: ____________________________________________________

Developed and reviewed by: American Camp Associat ion, First Last

American Academy of Pediat rics Council on School Health & ________________

Associat ion 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 yourP.O. Box 625 Saddle River, NJ 07458 child's doctor to complete pages 2 and 4.

Fax: 845-262-1091/email: [email protected] 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 06757 PLEASE KEEP A COPY FOR YOUR RECORDS.Fax: 860-927-4487/email: [email protected]

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: ________________

Email: ________________________________

Home Address: _____________________________________________________________________________________________

(If dif ferent from above) Street City State Zip

Second parent/guardian or other emergency contact:


Email: ________________________________

Additional contact in the event parent(s)/guardian(s) can not be reached:


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

Parent/Guardian Authorization for Health Center

This health history is correct and accurately reflects the health status o f the camper to whom it pertains. The person described has permission to participate in all camp activities except as

noted by me and/o r 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 fo rm 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.

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Male Female Birth Date

If yes, please provide copy of Insurance Card (Front and Back), thank you.

CAMPER HEALTH HISTORY FORM 2015 Camper Name: ___________________________________________

Developed and reviewed by: American Camp Associat ion, First Last

American Academy of Pediatrics Council on School Health & _______________________________Associat ion of Camp Nurses

forms from health-care providers or state or local government are acceptable; please attach to this form.

Immunization Dose 1 Dose 5 Most Recent Dose

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

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. /6 Rev. 1/2007 LEE/EAW

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Immunization History: Provide the month and year for each immunization. Starred (*) immunizations must be current. Copies of immunization

Dose 3

Month/Year

Dose 4

Month/Year

AS WELL AS THE STATE OF CT MEDICAL AUTHORIZATION FORM (last page of this document)

Birth Date:

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

When it is given

Dose 2

Month/Year

Reason for Taking it Amount or dose given How it is given

CAMPER HEALTH Camper Name: _____________________________________________________

HISTORY FORM 2015 First Last

Developed and reviewed by: American Camp Associat ion, 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): ________________________________________________ Phone: ____________________________

Name of dentist(s):_______________________________________________________________ Phone: ____________________________

Name of orthodontist(s): __________________________________________________________ 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.


PARENT / GUARDIAN: PLEASE COMPLETE THIS PAGE

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Camper Health History Form 2015 Camper Name: _______________________________________________ First Last

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 2015 1st Session

ACA Accreditation standards specify physical exam to be dated July 26, 2014 or later for 2015 2nd 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: ___________________________


CHILD'S DOCTOR TO COMPLETE AND SIGN THIS PAGE.

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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 www.campmeds.com.

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 20th.

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

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2015 camper health form v2 -...

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