2014 health form

HEALTH FORM
NOTE: ALL
MEDICATIONS
MUST BE IN
ORIGINAL
Winter Blast 3rd-6th 6th-8th Youth Camp CONTAINER WITH
Winter Blast Jr/Sr. High 9th-12th Youth Camp PHARMACY LABEL!
The information on this form is not part of the camper or staff acceptance process, but Developed and reviewed by: American Camp Association, & Association of Camp Nurses gathered to assist us in identifying appropriate care. Health history must be filled out Return this form with registration form To Parent(s)/Gurardian(s): Please follow the instructions below. Attach additional information as needed. 1) Complete registration form, complete this medical form front & back, please print. 2) Send the original signed Form with camper registration and mail by registration deadline. Walk Whitehall Camp & Conference Center
in registration is limited to availability. 580 Whitehall Rd
3) Make copy o f Health insurance card front & back & attach to this form or illegibility form for Emlenton PA 16373
Name ____________________________________________________________________ Birth date__________________________ Age at camp________________
Home address ______________________________________________________________________________________________________________________________ Social security number of participant __________________________________________________________________ Gender: Male Female Custodial parent/guardian ___________________________________________________________ Phone_____________________________________________ rst
Home address _______________________________________________________________________________________________________________________________ (if different from above) Street Address City State Zip Business address ______________________________________________________________________ Phone_____________________________________________ Second parent or guardian or emergency contact ____________________________________________________________________________________
Address ________________________________________________________________________________ Phone_____________________________________________ If not available in an emergency, notify _________________________________________________________________________________________________
Relationship ____________________________________________________________________________ Phone_____________________________________________ Address ______________________________________________________________________________________________________________________________________ Insurance Information
Is the participant covered by family medical/hospital insurance? Yes No If so, indicate carrier or plan name __________________________________________________ Group #_____________________________________________ Subscriber __________________________________________________ Insurance Company Phone Number Photocopy of front and back of health insurance card must be attached to this form.
Important — These boxes must be complete for attendance* This health history is correct and complete as far as I know. regulations promulgated pursuant to the Health Insurance The person herein named has permission to engage in all Portability and Accountability Act of 1996. I hereby agree (pursuant to 45 CFR § 164.510(b)) to the dis- I hereby give permission to the camp to provide, seek, and closure to camp representatives of the protected health infor- consent to routine health care, administration of prescribed mation of the person herein described, as necessary: (i) to medications, and emergency treatment for me/my child, as provide relevant information to the camp representatives relat- may be necessary, including, but not limited to x-rays, routine ed to the person’s ability to participate in camp activities; and tests and treatment, and/or hospitalization. I also give permis- (ii) in the case of minors, to provide relevant information to the sion for the camp to arrange related transportation. I agree to camp representatives to keep me informed of my child’s the release of any records necessary for treatment, referral, In the event I cannot be reached in an emergency, I hereby It is my intention that the camp be treated as acting in loco give permission to the physician selected by the camp to se- parentis if the person herein named is a minor. Further, it is cure and administer treatment, including hospitalization, for my intention that the appropriate representatives of the camp the person named above. This completed form may be photo- be treated as “personal representatives” for the purposes of copied for trips out of camp. disclosing protected health information pursuant to the privacy Signature of parent or guardian or adult camper/staffer ________________________________________________________________________________ Printed Name _____________________________________________________________________________________________ Date___________________________ I (camper) also understand and agree to abide by any restrictions placed on my participation in camp activities. Signature of minor or adult camper/staffer ______________________________________________________________ Date__________________________ Immunization History: Provide the month and year for each immunization. Starred ( ) immunizations must be current. Copies of immunization
forms from health-care providers or state or local government are acceptable; please attach to this form.
If your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from
not being fully immunized.
Signature of Custodial Relationship
Parent/Guardian: ______________________________________________________________Date: to Camper: __________________________
Medication: This camper will not take any daily medications while attending camp.
This camper will take the following daily medication(s) while at camp:
"Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Medication
must be in original container with pharmacy label with directions of dosage and time of administration on packaging/containers.
Provide enough of each medication to last the entire time the camper will be at camp.
Lunch Dinner Bedtime Other time: _______ Lunch Dinner Bedtime Other time: _______ Lunch Dinner Bedtime Other time: _______ The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness
and injury. Cross out those the camper should not be given.
Diphenhydramine antihistamine/allergy medicine (Benadryl) Dextromethorphan cough syrup (Robitussin DM) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Allergies: No Known Allergies
To foods (list):
To medications: (list):
To the environment (insect stings, hay fever, etc.– list):
Other allergies: (list):
Describe previous reactions:
What Have We Forgotten to Ask? Please provide in the space below any additional information about the camper’s health that you think
important or that may affect the camper’s ability to fully participate in the camp program. Attach additional information if needed.

Source: http://whitehallcamp.org/wp-content/uploads/2012/10/2014-Health-Form.pdf