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2012 Wooster Music Camp - Camper Health History
All information contained on this form will be treated confidentially and is for use by only camp staff in an effort to
provide appropriate and safe care for all campers (feel free to add any additional information on a separate sheet).
My child is in good health; none of the below information applies:
If your child has no known allergies, go to the next section.
1. Please list any known allergies that your child has (medications, foods, bee stings etc.):
2. Do any of these allergies require emergency medication? Please list (asthma inhaler, epipen, etc.):
3. Please share any other information about your child’s allergies and treatments that may be helpful: Prescription Medications:
If your child will not be taking any prescription medications, go to the next section.
1. Please list all prescription medications that your child will be taking while at Music Camp. A prescription
medication request form is required for all medications to be taken at camp. A Copy of this form is
included. Over-the-Counter Medications:
See OTC form on other side. If no other medications are needed, go to next
1. Please list all additional OTC medications that your child will be taking while at music camp. Include
dose(s) and time(s) to be administered. Current Health Concerns:
If no special health concerns, please go to next section.
1. Please list any health concerns about which our staff should be aware: Dietary/Activity Restrictions:
Other than as stated above.
1. Does your child have any dietary restrictions? Please explain:
2. Does your child have any activity restrictions while at camp? Please explain:
Dispensing of Over-the-Counter Medications
College of Wooster Music Camp 2012
Please return this completed form by June 29, 2012.
If your son/daughter has prescription medications other than an asthma inhaler,
insulin, or epipen, those medications must be left with the Camp’s Registered Nurse
who will dispense them throughout the week. You should place the medication in its
original container (with only the dosage needed for the week of camp) in a zip-lock
bag with the camper’s name clearly indicated on that container. If there are additional instructions needed for administration, please include those in the bag. Doing so before registration will greatly reduce the amount of time that campers
and their parents will spend in the lines on the day of registration. Thank you in
advance for your assistance in this matter. I.
As parent or guardian of ______________________, I give permission to the
camp nurse or other camp staff personnel to administer the following over-the-
counter medications to my child, as needed, while a camper at The College of
Wooster Music Camp.
Please initial all of those that can be given:
_____ Other (you supply): __________________
As parent or guardian of _______________________, I do not give permission
to the camp nurse or other camp staff personnel to give any over-the-counter
medications to my child while a camper at The College of Wooster Music Camp.
Dominique DETAILLE Born on september 17th, 1969 E-mail: firstname.lastname@example.org or email@example.com PhD in Biology Project: Scientific collaborator in a public or private research laboratory on Biomedical topics. Education 2002 - Ph.D. in Biology (Adviser: Professor Pierre Devos) Title: The Xenopus laevis oocyte as experimental tool for the study of an antidiabetic drug,
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