Health_form_13

BREENE’S CAMP RIVERBEND
116 Hillcrest Road, Warren, NJ 07059-5328Phone: (908) 580-CAMP Fax: (908) 647-2435 Camper’s
E-Mail: info@campriverbend.com • www.campriverbend.com Password:
If parent’s cannot be notified, please notify: Do you have any special recommendations for your child? (Include allergies, dietary restrictions, the need for earplugs, etc.) Please provide any information about your child that would make his or her camp experience more enjoyable: (Please do not include grouping
preferences here.)
May this child receive Tylenol: ■ Yes ■ No / Ibuprofen: ■ Yes ■ No / Neosporin: ■ Yes ■ No / Benadryl Spray: ■ Yes ■ No /
Benadryl: ■ Yes ■ No : If necessary during the camp session? Dosage will be adjusted per child’s age.
IN CASE OF MEDICAL EMERGENCY: Every effort will be made to contact parents. In event I cannot be reached, I hereby give permission to the physician select-
ed by the Camp Director to hospitalize and secure proper medical treatment for my child, named above. I hereby give the Camp Nurse permission to administer any
medications prescribed by a physician to my child during the camp session. I authorize any physician, nurse or other health care provider to communicate with the
medical staff and director of Camp Riverbend, or designee, about my child’s medical condition, treatment, and/or prognosis. I further authorize Camp Riverbend’s
medical staff to discuss any medical conditions with the director, designee or my child’s counselor(s) when the medical staff, in its sole discretion, believes such
communication to be in the best interest of my child. This authorization is limited to June through August of this year.
Signature Required
Signature of Parent / Guardian:
PHYSICIAN’S EXAMINATION
VACCINE TYPE
LEAD SCREENING
Mo/Day/Yr
Mo/Day/Yr
Mo/Day/Yr
Mo/Day/Yr
Mo/Day/Yr
Test Date
(DTaP) or any combination* If TD or DT, indicate in corner box POLIO – INACTIVATED POLIOVACCINE (IPV)If oral vaccine, indicate (OPV) in corner box Document below single antigen vaccine receipt,
serology titers, or varicella disease history
■ Provisional Admission Attached – Date Granted ■ Medical Exemption Attached ■ Religious Exemption Attached * REQUIRED MEDICAL EXEMPTION ** REQUIRED FOR DAY /CHILDCARE ENROLLEES (2 Months - 5th Birthday only) *** NOT REQUIRED Does this allergy require emergency treatment (like epi-pen?) ■ Yes* ■ No Does this allergy require emergency treatment (like epi-pen?) ■ Yes* ■ No Does this allergy require emergency treatment (like epi-pen?) ■ Yes* ■ No *If yes, fill out the following Authorization for Emergency Medication
Does the child have a history of any chronic or recurring illnesses? ■ Yes ■ NoIf yes, what is the nature of the illness? Does the child take any prescribed medications regularly? ■ Yes ■ NoMedication: Dosage: Will this child need prescribed medication during the camp day? ■ Yes* ■ No
*If yes, fill out the following Medication Administration Authorization
needs to take prescription medication at camp. MEDICATION ADMINISTRATION AUTHORIZATION
Camper’s Name__________________________________
Group________
Home Phone Number_____________________________
TO BE FILLED OUT BY PHYSICIAN:
Please administer the following medication to the above named student as prescribed below:
Medication/Dose________________________________________________________
Reason for Medication___________________________________________________
Time to be Administered_________________________________________________
To be given from (date)_______________________Stop Date___________________
Side Effects to be reported________________________________________________
Physician’s Stamp:
Physician’s Signature:____________________________________________________
TO BE SIGNED BY PARENT/GUARDIAN:
I give my permission for the above medication to be administered to my child at Camp
Riverbend. I realize that any changes or modifications of this order will require a written
authorization from this physician.
Parent/Guardian’s
Signature___________________________________Date____________________
Doctor and Parent must complete this form ONLY IF child may require emergency medication for an allergic reaction at camp. Authorization for Emergency Medications for Allergic Reaction
Camper Name: ___________________________________________________
Date of Birth: ___________________________Group: __________________
Allergic To: ______________________________________________________

Signs of Allergic Reaction: Circle all that apply
Systems:
Symptoms:
Itching and swelling of the lips, tongue or mouth Hives, itchy rash, and/or swelling about face or extremities Itching and/or tightness in the throat, hoarseness and cough Nausea, abdominal cramps, vomiting, and/or diarrhea Shortness of breath, repetitive cough, wheezing or chest tightness All above symptoms can potentially progress to a life-threatening situation.
I hereby certify that the camper listed above has been instructed in and is fully capable of
the self-administration of the epi-pen. YES____ NO____
Action Plan for an Allergic Reaction:
Chose from the following options:
1. Benadryl
YES ______ Benadryl________mg. p.o.
Notify parent. Campers with allergic reaction will be sent home.
In the absence of the nurse, the order for benadryl should be disregarded and epinephrine
is to be immediately administered by the designated delegate.
2. Epi-Pen 0.15mg syringe _______
Epi-Pen 0.3mg syringe ________
If symptoms of anaphylaxis persist repeat epi-pen administration in 10-15 minutes. YES______ NO______
Call Rescue Squad or 911 and ask for advance life support. Notify parents/guardian.
Transport to nearest Emergency Room. Camper must have access to epinephrine in
camp.

Physician Signature:__________________________________Date___________
Physician Stamp:
____________________________________________________________________
Parent Signature: ________________________
Date_____________

Medication___________________#Pens Recieved_____ Expiration Date: ________
Camp Nurses’ Signature________________________
Date______________

Camper Name: ___________________________________________________

Source: http://www.campriverbend.com/sites/default/files/Camp%20Riverbend%20medical%20form%202013_0.pdf