Berkshire Humane Society ~ 214 Barker Road, Pittsfield, MA 01201 ~Camp Humane - 2009 Health Form THIS SIDE TO BE FILLED OUT and SIGNED BY PARENT/GUARDIAN
BACK SIDE TO BE FILLED OUT and SIGNED BY A PHYSICAN
This form MUST be received by the first day of camp or the child CANNOT attend camp.
Child’s Name_________________________ Date of Birth ___________ Age_____ Parent/Guardian____________________________________________________ Address____________________________________Email__________________ City____________________ State______ Zip_________ Home Phone_______________________ Work/Cell _______________________ Child’s health history (check illness child has had, with approximate dates): Frequent ear infections _______ Chicken Pox _______ Allergies: Heart defect/disease _________ Measles ___________ Pet dander _____________ Convulsions _______________ Rubella ___________ Food _________________ Diabetes __________________ Mumps___________ Insect Stings ___________ Bleeding/clotting Disorder_____ Mononucleosis______ Hay Fever _____________ Hypertension_______________ Asthma___________ Penicillin _____________ ____________ Operations or serious injuries (specify dates):______________________________ ______________________________________________________________________________ Disability or chronic recurring illness:___________________________________ Taking any medications Y/N ______________________________ Will they be taken during the camp program Y/N Instructions___________________ Any specific activities to be encouraged or limited by physician’s advice: ________________________________________________________________ _______________________________________________________________________________ Dietary Modifications:_____________________________________________________ Food allergies or intolerances:_______________________________________________________ Name of Physician:______________________________Phone:_____________________ Date of last physical exam:________ Medical insurance carrier:_________________ This health history is correct so far as I know, and the child described has permission to engage in all program activities except as noted above. Emergency authorization: I hereby give permission to the medical personnel selected by the Program Director to order x-rays, routine tests and treatment for my child, and in the event I cannot be reached in an emergency, I give permission to the physicianselected by the program director to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named above. Parent/Guardian Signature: ____________________________________
THIS SIDE MUST BE COMPLETED AND SIGNED BY PHYSICIAN Please record date of basic immunization and most recent booster:
Vaccine Date of basic immunization Date of Booster
_______ or_______________________________________________________________________________________________________ Tetanus Diphtheria
__________or________________________________________________________________________________________________________ Tetanus _________________________________________________________________________________________________________ Oral Polio (Sabin) TOPV
_________________________________________________________________ ______________ _______________________________________________________ Measles_______________________________________________________ Mumps _____________________________________________________________ Rubella (German measles) __________________________________ Other ________________________________________________________________ Tuberculin test given
Health examination by licensed physician: I have examined camp program applicant: ____________________________________________________ Date_____________________
The child’s health does __________ does not ___________ preclude participation in an active camp program.
The child is under the care of a physician for the following condition(s) _______________________________________________________________
Please Note: An actual copy of the patient’s immunization records or check up evaluation can be used instead of this page. The Berkshire Humane Society does not accept camper health records through the internet.
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