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Microsoft word - camperhealthcarerec.doc
CAMPER HEALTHCARE RECOMMENDATIONS BY LICENSED MEDICAL PERSONNEL FORM 2
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: _______________________________________________________________________
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 ________/________
No known allergies
those items the
The environment (insect stings, hay fever, etc.) (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)
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).
Ibuprophen (Advil, Motrin) Ivy Dry Laxatives for constipation (Ex-Lax) Lice shampoo or cream (Nix or Elimite)
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)
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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