Health Form

Health History Form

Parent portion of health form

Camper's Legal Name(Required)

First

Middle

Last

Male

Female

Birth Date(Required)

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Parent/guardian with legal custody to be contacted in case of illness or injury:

First

Last

Relationship to camper(Required)

Phone(Required)

Email(Required)

Address (if different from camper)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Second parent/guardian or other emergency contact:

Name(Required)

First

Last

Relationship to Camper:(Required)

Phone(Required)

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

Name

First

Last

Relationship to camper:

Phone

Medical Insurance Information

Is this camper covered by family medical/hospital insurance?

Yes

General Health History

Check "Yes" or "No" for each statement.

Has/does the camper:

Ever had surgery?(Required)

Yes

Ever been hospitalized?(Required)

Yes

Have recurrent/chronic illnesses?(Required)

Yes

Had a recent infectious disease?(Required)

Yes

Had asthma/wheezing/shortness of breath(Required)

Yes

Had a recent injury?(Required)

Yes

Have diabetes?(Required)

Yes

Had seizures?(Required)

Yes

Had headaches?(Required)

Yes

Wear glasses or contacts?(Required)

Yes

Had fainting or dizziness?(Required)

Yes

Passed out/had chest pain during exercise(Required)

Yes

Had mononucleosis during the past year?(Required)

Yes

Have problems with falling asleep?(Required)

Yes

If female, have menstruation problems?(Required)

Yes

Have history of sleepwalking?(Required)

Yes

Ever had back/joint problems?(Required)

Yes

Have a history of bedwetting?(Required)

Yes

Have problems with diarrhea/constipation(Required)

Yes

Have any skin problems?(Required)

Yes

Traveled outside the country in the past 9 months?(Required)

Yes

Please explain "Yes" answers in the space below.

For travel outside of the country, please name countries visited and travel dates.

Mental, Emotional, and Social Health:

Check "Yes" or "No" for each statement.

Has the camper:

Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperctivity disorder (AD/HD)?(Required)

Yes

Ever been treated for emotional or behavioral difficulties or an eating disorder?(Required)

Yes

During the past 12 months, seen a professional to address mental/emotional health concerns?(Required)

Yes

Had a significant life event that continues to effect the camper's life?(Required)

Yes

(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.

The camp may contact your for additional information.

Medications

"Medication" is any substance a person takes to maintain and/or improve their health. This INCLUDES vitamins & natural remedies. The camp requires original pharmacy containers with labels which show the camper's name and how the medication should be given. Parents need to provide enough of each medication to last the entire time the camper will be at camp.

Does your camper take any prescription or OTC medications?(Required)

Yes

If so a MD/NP/PA must write a prescription!

Medications given at BREAKFAST

Name of Medication

Dose

Name of medication

Amount or dose given

How is it given?

When is it given?

Reason for taking it?

Date sarted

Do you need to enter an additional medication?

Yes

Name of medication

Amount or dose given

How is it given?

When is it given?

Reason for taking it?

Date started

Do you need to enter an additional medication (2)

Yes

Name of medication

Amount or dose given

How is it given?

When is it given?

Reason for taking it?

Date started

Do you need to enter an additional medication (3)

Yes

Name of medication

Amount or dose given

How is it given?

When is it given?

Reason for taking it?

Date started

Non-Prescription medications (only click on an item if it SHOULD NOT be given)

These non-prescription medications are commonly stocked in camp health Centers and are used on an as-needed basis to manage illness and injury. Please click on any medication the camper SHOULD NOT be given.

Allergies and Asthma

Does the camper have Asthma?(Required)

Yes

Does the camper need to carry an inhaler with them?

Yes

Another form needs to be filled out by a doctor if the camper has permission to self-administer an inhaler.

Does the camper have food allergies?(Required)

Yes

Please list food allergies

Does the camper have allergies to any medications?(Required)

Yes

Please list medication allergies

Does the camper have allergies to the environment (insect stings, hay fever, etc)(Required)

Yes

Please list environmental allergies

Does the camper have any other allergies that aren't previously listed?(Required)

Yes

Please list other allergies

Does the camper need to carry an epi-pen

Yes

Another form needs to be filled out by a doctor if the camper should self administer an epidural-pen.

Please describe allergic reactions.

Parent/Guardian Authorization for Health Care:

Consent(Required)

I agree to the authorization for Health Care

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 th 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.

Parent signature

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