Day camp health form 2013

COMPLETE AND MAIL WITH PARTICIPANT RELEASE FORM (Keep a copy for your records) Last Name: _______________________ First Name: ______________________
Male ___ Female ___ Birth Date: ___ / ____ / ____
Health Insurance: ___________________________________ Policy # __________________________________________ I have no Insurance _____ HEALTH HISTORY
Does the camper have a history of any of the following? (Check all that apply)
___Seizures / Convulsions ___ Fainting / Dizzy Spells ___ Head Injury ___ Frequent Headaches
___ Heart Disease / Defect ___ High Blood Pressure ___ Frequent Ear Infections ___ Cancer / Leukemia ___ Bleeding / Clotting Disorder ___ Menstrual Problems ___ Kidney Disease ___ Mononucleosis ___ Altitude Sickness---- Sleepwalking ___ Eating Disorder ___ Asthma ___ ADD /ADHD ___ Bi-Polar ___ _________ Please explain any history that may impact the camper’s camp experience or special care that should be taken __________________________________ ________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ALLERGIES
____ Medications _______________________ ___ Foods ____________________________ ___ Insect Stings ___________________________ SPECIAL DIET
___ Vegetarian ___ Gluten Free ___ Lactose Free ___ Please describe any special dietary restrictions or requirements ________________________ ________________________________________________________________________________________________________________________ 1. All prescription medications, over-the-counter medications, and Vitamins MUST be in the original container with current accurate directions.
2. Pill minders, plastic bags, etc, are not acceptable for any medication.
3. Place all medication containers together in a plastic zip-lock bag with the camper’s name on it.
4. Campers are responsible for going to the infirmary at specified times for medication.
5. Campers will be allowed to carry asthma inhalers & epi pens with them.
Please provide the following information for EACH medication you are bringing to camp, including vitamins and over-the-counter medication.
Medication Name: __________________________________________ Reason for Giving: _________________________________________ Frequency Given: ___ As Needed ___ Daily ________ time(s) per day Dosage: _________________ ___ Taken with Food Special Instructions: _______________________________________________________________________________________________________ If you have more than one medication check here_____ and include this information on back of this page.
Over-the-Counter medications
These are the over-the-counter medication stocked in the health clinic at Sky Ranch. These medications are overseen and administered by
our volunteer health supervisor. Please check off any medications that YOU DO NOT APPROVE and initial here ______.
___Calamine Lotion (rashes, insect bites) ___ Diphen / Benedryl (allergy, itching, rashes) By signing below, you approve the administration of these over-the-counter medications for the camper listed above.
___ I approve of the over-the-counter medications listed above for use as needed by the camper identified above. I have checked off any medicationsthat are not approved for use by said camper.
___I hereby request and give my permission to the Sky Ranch Lutheran Camp health supervisor to administer medication to the camper identified above.
I understand that all medication must be provided in the original pharmacy labeled container. I understand my child assumes responsibility for going tothe health supervisor at the specified times for medications.
___I hereby give my permission to Sky Ranch Lutheran Camp to give care to the camper identified above in case of illness and understand Sky RanchLutheran Camp will attempt to contact me in such event.
All camp participants must also complete the Colorado Health Department Certification of immunization (available at Signature of Parent, Guardian, or Adult Participant Date –look for forms) For out-of-state participants who may not be up-to-date for Colorado standards, the parent/guardian/adult may sign the personal exemption section.


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