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Microsoft word - camperhealthcarerec.doc

To Parents(s)/Guardian(s): Complete this section and give this form (FORM 2) and a copy of your completed
CAMPER HEALTH HISTORY FORM (FORM 1) to your child’s health-care provider for review. Camp Glen Brook
Dates will attend camp: _____/_____/_____ to _____/_____/_____ 35 Glen Brook Rd.
Month Day Year Month Day Year Marlborough, NH 03455
Camper Name: _______________________________________________________________________ Questions?
F Birth Date: _____/_____/_____ Age on arrival at camp _________ ___________________________________________________________________________________________________ Custodial parent(s)/guardian(s) telephone: (______) _______________________________ PARENT(S)/GUARDIAN(S) STOP HERE. REST OF FORM TO BE COMPLETED BY MEDICAL PERSONNEL.
Physical exam done today: □ Yes □ No (If no, date of last physical _____/_____/_____)
ACA accreditation standards specify physical exam within last 24 months. Center and will be used on an as needed basis to manage illness Weight _______ lbs Height ________ft _______ in Blood Pressure ________/________ Allergies: No known allergies
CROSS OUT those items the
Food (list)
Medicine (list)
The environment (insect stings, hay fever, etc.) (list)
Other (list)
Antibiotic cream, topical Antihistamine/allergy medicine Describe previous reactions:
Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Calamine lotion Chlorpheniramine maleate Dextromethorphan cough syrup (Robitussin DM) Diet, Nutrition: This camper eats a regular diet Has a medically prescribed meal plan or dietary
restrictions: (describe below)
Guaifenesin cough syrup (Robitussin) Hydrocortisone Cream This camper is undergoing treatment at this time for the following conditions: (describe below). None
Ibuprophen (Advil, Motrin) Ivy Dry Laxatives for constipation (Ex-Lax) Lice shampoo or cream (Nix or Elimite) Medication: No daily medications Will take the following prescribed daily medication(s) while at camp.
(name, dose, frequency – describe below)
(Sudafed PE) Pseudoephedrine decongestant Other treatments/therapies to be continued at camp: (describe below) None needed

Do you feel that the camper will require limitations or restrictions to activity while at camp?
□ No □ Yes
If you answered “Yes” to the question above, what do you recommend? (describe below – attach additional information if needed)
“I have reviewed the CAMPER HEALTH HISTORY FORMS (FORM 1), and have discussed the camp program with the camper’s parent(s)/guardian(s). It is my opinion that the camper is physically and emotionally fit to participate in an active camp program (except as noted above). Name of licensed provider (please print): ________________________________________ Signature ______________________________________ Title ___________________ Office Address ___________________________________________________________________________________________________ Street Address City State Zip Code Telephone (______) _______________________________ Date _____/_____/________ Copyright 2008 by American Camping Association, Inc. Rev. 2/2007 LEE/EAW


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