Operation military kids healthcode of conductphoto form 13-14.pub (read-only)

2013-2014 4-H Youth Development
Health - Code of Conduct - Photo Form Operation Military Kids
IMPORTANT – The following information must be com-
RECENT MEDICAL HISTORY
pleted for attendance!
Please check yes or no. If yes, explain (include another sheet if need- ____ ____Has the participant had any recent surgeries or fractures? Participant’s Name____________________________________________________ ________________________________________________________ Birth date_________________________________ Age_______ Sex __________ ____ ____ Does the participant have any chronic health problems or illness, Address_____________________________________________________________ ________________________________________________________ City _____________________________State ______ Zip Code _______________ ____ ____ Does the participant presently have an acute illness? ________________________________________________________ ____ ____ Has the participant been treated recently for any kind of medical Home phone________________________________________________________ ________________________________________________________ Parent or guardian____________________________________________________ ____ ____ Does the participant have any allergies to medication or local Work phone ________________________________________________________ _______________________________________________________ Second parent or guardian_____________________________________________ ____ ____ Does the participant have contacts, glasses, orthodontic appliances? Address______________________________ City _______________State______ ________________________________________________________ Home phone_____________________________ Work phone_________________ ____ ____Are the immunizations up-to-date? If not available in an emergency, notify: Date of last tetanus: _____________________________ ___________________________________________________________________ List any allergies to medications and/or foods
Address: __________________________ City __________________ State ______ ______________________________________________________________________
Home phone_______________________ Work phone_______________________ ______________________________________________________________________

List any medications he/she is now taking for treatment of any medical problem.:
_________________________________________________________________
HEALTH INSURANCE INFORMATION
Activities encouraged or limited by physician: Policyholder’s name and relationship to participant:__________________________ _________________________________________________________________ ___________________________________________________________________ Policyholder’s address:________________________________________________ _________________________________________________________________ Insurance company‘s name and address:__________________________________ ___________________________________________________________________ For Females:
If you have HMO insurance, please list emergency treatment authorization phone Has this person menstruated? ________ If not, has she been told number:____________________________________________________________ about it? ______ If so, is her menstrual history normal? _______ Special consideration____________________________________ Employer’s name and address________________________________________ _____________________________________________________ All policy numbers (please identify):_______________________________________ This health history is correct, to the best of my knowledge, and the per- ___________________________________________________________________ son herein described has my permission to engage in all activities, ex- cept as noted.
Signature of parent, guardian or adult camper/staff member:
MEDICAL TREATMENT AUTHORIZATION
_________________________________________________ Date________________
Primary care physician________________________________________ Authorization for Treatment: I hereby give permission to the medical personnel,
selected by the activity director, to order X-rays, routine tests, treatment, permis-
Physician’s phone___________________________________________ sion to release any record necessary for insurance purposes, and to provide and Dentist or Ortho phone _______________________________________ arrange necessary related transportation for me/my child. If I cannot be reached in the event of an emergency, I hereby give my permission to the physician se-lected by the camp director to secure and administer treatment, including hospital- Please tell us anything about your child that you feel might be helpful or ization for the person named above. This complete form may be photocopied in necessary for us to know in order to improve his/her camping experience. the event the participant will need to leave camp. (For example: stomachaches when nervous, bedwetting, sleepwalking, Tylenol works best for headaches, etc.) This will be shared confidentially Signature of parent, guardian or adult camper/staff member:
__________________________________________ Date: _________
_________________________________________________________________________ I, as the participant, understand and agree to abide by the restrictions _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Signature of minor or adult camper/staff member:
_________________________________________________________________________ __________________________________________ Date:__________
_________________________________________________________________________ *If for religious purposes you cannot sign this, the camp should be con-tacted for a legal waiver, which must be signed for attendance. Health — Code of Conduct — Photo Form
SECTION I – HEALTH FORM .continued
SECTION III—DELAWARE 4-H
CODE OF CONDUCT
PERMISSION TO MEDICATE
I understand that my child may require medication for minor medical conditions. Such conditions may include headaches, sunburn, poison Attend all sessions in the planned program. If you ivy, bug bites, upset stomach, scrapes, cuts, and/or bee bites. I un- are not feeling well or have a schedule conflict that derstand there will be a camp nurse to handle minor health problems will keep you from attending, please tell the adult in and medication administration, but the camp nurse will not be able to medi- cate my child without permission from the parent or guardian. The following Follow hours and room rules established before the over-the-counter medications may be administered to my child, as needed, event begins. You are responsible to know the rules following the suggested dosage guidelines (initial all that you give permis-
sion for the camp nurse to administer.) Medication and/or conditions not
Use language and manners that will bring respect to covered by your advance permission will require a phone call to you before any medication can be given, and may cause a delay in treatment.) you and Delaware 4-H. You are responsible to know which language and behavior is appropriate. _______ Tylenol for headaches, muscle aches and pains, cramps Be in the assigned program area (dorms, cabins, _______ Advil for headaches, muscle aches and pains, cramps _______ Maalox, Mylanta for upset stomach, stomachache, gas, nausea Know the use of tobacco, alcohol and non- prescription drugs is prohibited at all times and at all _______ Tums for stomachache, upset stomach, nausea Model respect for other persons in public areas. The _______ Pepto-Bismol for nausea, diarrhea adults in charge will help you know rules of courtesy _______ Milk of Magnesia for constipation Treat program areas, lodging areas and transporta- _______ Calamine, Caladryl, Insect Bite Pen for insect bites, stings, jelly tion vehicles with respect and care. You will be re- sponsible for any damage, theft, or misconduct in _______ Benadryl Lotion (topical) for insect bites, stings, poison ivy _______ “Green Clay” (from health food store) for poison ivy, insect bites, Help other members in your group have a pleasant experience by making every attempt to include all _______ Adolf’s Meat Tenderizer (enzyme deactivates the poison) for jelly fish stings _______ Neosporin, Hydrogen Peroxide for scrapes and cuts Live up to your highest expectations of yourself, so you can return home proud of who you are and what _______ Benadryl (oral) for sinus, allergies, hay fever, rashes Those who are unable to conduct themselves within
the guidelines listed above will be expected to:
I understand any prescription medications taken by my child and/or to be Explain their actions to the adults in charge; dispensed to my child MUST be in the original container from the pharmacy Accept the consequences of their actions; with the original label and directions attached, or I must have a copy of the Know that the adults in charge will work closely with par- prescription from the doctor, in order to be dispensed by the camp nurse. ents/guardians, Extension personnel, and others to see (Failure to follow these rules will result in the parent or guardian being re- that action is taken, and that appropriate and logical conse- quired to deliver these before any medications can be given.) Signature of parent or guardian:
I have read the Delaware 4-H Code of Conduct and agree
_____________________________________________ Date__________
to live up to the expectations. I realize my failure to do
so could result in the loss of privileges during this event
SECTION II—PHOTO IMAGE RELEASE
and/or in the future.
Participant Signature _______________________Date_____________

I authorize the University of Delaware to record and photograph my image and/or voice, or that of my child, for use by the University of Delaware or As parents/guardians of_____________________________ its assignees in research, educational, and promotional programs. I un- derstand and agree that these audio, video, film and/or print images may I have read the Delaware 4-H Code of Conduct and will sup- be edited, duplicated, distributed, reproduced, broadcast and/or reformat- port the adults in charge in the performance of their responsi- ted in any form and manner without payment of fees, in perpetuity. bilities to see that appropriate behavior is maintained. Subject’s name (adult or youth)_______________________________
Parent/Guardian Signature:

_______________________________________________________Date_________
Signature ___________________________________ Date _________

Source: https://extension.udel.edu/4h/files/2012/02/Operation-Military-Kids-HealthCode-of-ConductPhoto-Form-13-14.pdf