Microsoft word - health form 2013.doc

Health Form - Chapel Rock Summer Camps 2013

The information on this form is not part of the camper or staff acceptance process, but is gathered to assist us in identifying appropriate care. Health history (first three
pages) must be filled out by parents/guardians of minors or by the adults themselves. Update required annually. Health exam (fourth page) to be completed by
approved licensed medical personnel is optional but recommended at least every two years. This form must be returned two weeks prior to your camp start date.

Camper Name __________________________________________________________________________________________________________________________
Home Address __________________________________________________________________________________________________________________________ Birth date __________________ Age at Camp ______________ Grade (Spring 2013) ____________
Church ___________________________________________________________________
Custodial parent/guardian _______________________________________________________________ Home phone ____________________________________
Home address __________________________________________________________________________________________________________________________
(if different from above) Street
Business Phone _____________________________________________ Cell phone/pager _________________________________________________________
Second parent or guardian _______________________________________________________________ Home phone ____________________________________
Home address ___________________________________________________________________________________________________________________________
(if different from above) Street
Business Phone _____________________________________________ Cell phone/pager _________________________________________________________
If not available, in an emergency, notify ____________________________________________________ Relationship _____________________________________
Home phone ___________________________________ Business phone ________________________________ Cell phone/pager ____________________________
Important – These boxes must be completed for attendance*
Consent for Treatment: The information given on this form is correct and
to provide relevant information to the camp representatives to keep me complete as far as I know. The person here-in named has permission to engage in all camp activities except as noted. In the event I cannot be reached in an emergency, I hereby give permission to I hereby give permission to the camp to provide, seek, and consent to routine the physician selected by the camp to secure and administer treatment, health care, administration of prescribed medications, and emergency including hospitalization, for the person named above. This completed form treatment for me/my child, as may be necessary, including, but not limited to may be photocopied for trips out of camp. x-rays, routine tests and treatment, and/or hospitalization. I also give permission for the camp to arrange related transportation. I agree to the Activity Disclosure: Chapel Rock programs vary by age groups, but may
release of any records necessary for treatment, referral, billing, or insurance involve a variety of activities that include warm-ups, games, group initiatives, and high and low ropes course elements. Activities may also include swimming, rock climbing, rappelling, kayaking, canoeing, and orienteering. It is my intention that the camp be treated as acting in loco parentis if the All programs are conducted by trained professional staff, yet there is a risk person named herein is a minor. Further, it is my intention that the that must be assumed by each participant. By signing below, I give my appropriate representatives of the camp be treated as “personal consent for my camper to participate in these activities, except as noted representatives” for the purpose of disclosing protected health information elsewhere on this form. I further consent that my child may be transported by pursuant to the privacy regulations promulgated pursuant to the Health school/commercial bus or van for off site camp activities. I understand that Insurance Portability and Accountability Act of 1996. I hereby agree Chapel Rock and the Episcopal Diocese of Arizona assume no liability for (pursuant to 45 CFR 164.510(b)) to the disclosure to camp representatives of accidental injury to my child during his/her stay at camp. the protected health information of the person herein described, as necessary: (i) to provide relevant information to the camp representatives related to the In the event of the withdrawal or dismissal from camp for any reason other person’s ability to participate in camp activities; and (ii) in the case of minors, than illness requiring the attention of a physician, I will pay the camp fee in full.
Photo release: May we use photos or videos of your camper for camp promotional materials?
Signature of parent or guardian or adult camper/staffer _________________________________________________________________________________________
Printed name ___________________________________________________________________________________________________ Date ___________________


I also understand and agree to abide by any restrictions placed on my participation in camp activities.
Camper signature ________________________________________________________________________________________________ Date ___________________




Health History
The following information must be filled in by the parent/guardian, or adult
Any changes to this form should be provided to camp health personnel upon camper or staff member. The intent of this information is to provide camp participant’s arrival in camp. Provide complete information so that the camp health care personnel the background to provide appropriate care. Keep a copy of the completed form for your records.
ALLERGIES List all known.
Describe reaction and management of the reaction.
Medication allergies (list)
______________________________
___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________
Food allergies (list)
______________________________
___________________________________________________________________________________________________ ___________________________________________________________________________________________________
Other allergies (list) – include insect stings, hay fever, asthma, animal dander, etc.
______________________________
___________________________________________________________________________________________________ ___________________________________________________________________________________________________
MEDICATIONS BEING TAKEN

Please list ALL medications (including over the counter or nonprescription
physician (if a prescription drug), the name of the medication, the dosage, and drugs) taken routinely. Bring enough medication to last the entire time of camp. Keep it in the original packaging/bottle that identifies the prescribing  This person takes NO medications on a routine basis.  This person takes medications as follows: Med # 1 ________________________________________ Dosage _______________ Specific times taken each day _________________________________ Reason for taking ________________________________________________________________________________________________________________ Med # 2 ________________________________________ Dosage _______________ Specific times taken each day _________________________________ Reason for taking ________________________________________________________________________________________________________________ Attach additional pages for more medications. Identify any medications taken during the school year that participant does/may not take during the summer: ___________________________________________ __________________________________________________________________________________________________________________________________
The following non-prescription medications may be administered under the direction of the camp nurse. Any medications you DO NOT want your camper to take,
please cross out.
Antibiotic ointment

RESTRICTIONS
The following restrictions apply to this individual:
Dietary
 Does not eat red meat

 Other (describe) ____________________________________________________________________________________________________________________
Explain any restrictions to activity (e.g., what cannot be done, what adaptations or limitations are necessary, swimming ability) ______________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
GENERAL QUESTIONS (Explain “yes” answers below)
Had a recent injury, illness, or infectious disease?.  16. Ever had joint problems (e.g., knees, ankles)?.  Have a chronic or recurring illness/condition?.  18. Have any skin problems (e.g., itching, rash, acne)?  21. Had mononucleosis in the past 12 months?.  Ever been knocked unconscious? …………………….  22. Had problems with diarrhea/constipation?.  Wear glasses, contacts or protective eyewear?.  23. Have problems with sleepwalking?.  Ever had frequent ear infections? …………………….  24. If female, have an abnormal menstrual history?.  10. Ever passed out during or after exercise?.  11. Ever been dizzy during or after exercise?.  13. Ever had chest pain during or after exercise? ……….  28. Ever had emotional difficulties for which 15. Ever been diagnosed with a heart murmur?. 
Please explain any “yes” answers, noting the number of the questions.
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Which of the following
Please give all dates of immunization for:
has the participant had?

Use this space to tell us more about your camper. Please provide any additional information about the participant’s behavior and physical, emotional, and
mental health about which the camp should be aware. Have there been any recent changes in your family life that the camp should be aware of? What goals
do you or your camper have for their camp experience?
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
Name of family physician ____________________________________________________________________ Phone ______________________________________
Address ______________________________________________________________________________________________________________________________
Name of family dentist/orthodontist ____________________________________________________________ Phone ______________________________________
Address ______________________________________________________________________________________________________________________________

Is the participant covered by family medical/hospital insurance?
If so, carrier or plan name __________________________________________________________ Group # _________________________________  Photocopy of front and back of health insurance card must be attached to this form.
Health Care Recommendation by Licensed Medical Personnel
I examined this individual on _______________. (Chapel Rock recommends exams within 24 months of camp attendance.) BP _____________________ Weight __________________
In my opinion, the above applicant  is  is not able to participate in an active camp program.
The applicant is under the care of a physician for the following condition(s):
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Recommendations and Restrictions at Camp
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 ____________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Description of any limitation or restriction on camp activities _________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Additional information for health staff at the camp _________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Signature of Licensed Medical Personnel _______________________________________________________________________________________________
Printed ___________________________________________________________________________ Title ____________________________________________
Address ___________________________________________________________________________________________________________________________
Phone _____________________________________________________________________________ Date __________________________________________
For camp use only
Screening Record
Date screened ___________________________________________________________________________ Time ___________________ AM
Meds received ______________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ Updates/additions to health history noted Current health needs identified _________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ Observational notes __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ Screened by _____________________________________________________________

Source: http://www.chapelrock.net/pdf/health-form.pdf