Emergency contacts

Please complete and return to:
Director of Programs
152 Madison Avenue, Suite 2400
New York, NY 10016
PHYSICIAN'S EXAMINATION FORM
Must be completed by a Physician
Name: ________________________________________ Date of Birth (month/date/year): ________________ Sex (M/F): ________ Height: __________ Weight: _________ Blood Pressure: _____________ Date of exam (month/date/year):___________________ Teeth: ___________________________ Nervous System: ___________________ Gums: ___________________________ Please comment if Camper is capable of full activity in the program including a four-day hiking trip: _________________________________________________________________ _________________________________________________________________ General comments and recommendations: _________________________________________________________________ _________________________________________________________________
Treatment to be continued during the program including all prescription, over-the-counter medications
and vitamins (please complete one Camper Medical Authorization Form for each of these treatments):
_________________________________________________________________
_________________________________________________________________
Signature of licensed medical practitioner: ______________________________ Date: ____________
Print Name: ___________________________ Telephone: __________________________________
Address: __________________________________________________________________________
___________________________________________________________________________________
Page 1 of 7
Camper Forms Packet
Please complete and return to:
Director of Programs
152 Madison Avenue, Suite 2400
New York, NY 10016
PAST HEALTH HISTORY
May be filled out by parent/guardian but must be signed by a physician
NAME: ______________________________________
Check any that apply and give further information, dates, and explanation below.

_____recent injury, illness or infectious diseases
_____ever had joint problems (knees, ankles, etc.) _____chronic or recurring illness or condition _____ever been dizzy during or after exercise` _____abnormal menstrual history (females) _____ever been diagnosed with a heart murmur _____mononucleosis in the past 12 months _____ever had emotional difficulties for which _____problems with diarrhea/constipation
Explanations of above:
_______________________________________________________________________________
_______________________________________________________________________________ _______________________________________________________________________________
Allergies
List all known. Describe reaction (including asthma) and treatment needed.
Medication Allergies (list) ___________________ ________________________________________________________ ___________________ ________________________________________________________ ___________________ ________________________________________________________ Food Allergies and treatment needed (list) ___________________ ________________________________________________________ ___________________ ________________________________________________________ ___________________ ________________________________________________________
Other allergies/treatment needed (list) include insect stings, hay fever, animals, dust,
etc.
___________________ ________________________________________________________
___________________ ________________________________________________________ ___________________ ________________________________________________________ Page 2 of 7
Camper Forms Packet
Please complete and return to:
Director of Programs
152 Madison Avenue, Suite 2400
New York, NY 10016
Past Health History-CONTINUED

NAME: ______________________________________ DATE___________________________
Disease History
Which of the following diseases has the Camper had?

Explanations of above including dates of symptoms and treatments:
_______________________________________________________________________________
_______________________________________________________________________________ _______________________________________________________________________________
TB Mantoux Test
Health Department or Doctor’s card needed as proof of test results.
GIVE ALL DATES OF IMMUNIZATION for:
This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted. ___________________________________________________ _________________ Signature of parent or guardian (for minors) or self

________________________________________________________ ____________________
Physician’s
___________________________________________________ _________________ Page 3 of 7
Camper Forms Packet
Please complete and return to:
Director of Programs
152 Madison Avenue, Suite 2400
New York, NY 10016
INDIVIDUALIZED STANDING ORDERS
FOR “OVER-THE-COUNTER” MEDICATION

Orders for _________________________for the following products to be administered if and when
needed at Camp Rising Sun.

To the Healthcare Provider: Please circle "Yes" or "No" for each product AND SIGN AT THE
END. These products are almost all available without a prescription in the U.S., but we must have a
doctor's permission to use them as needed. For further information about specific products in
English or Spanish, please see www.drugs.com.
Camper's
Drug Name
(please circle
Schedule and
Health Care Comments
preferred
Indications
Provider
formulation(s))
Tylenol/
Acetaminophen (chewable tabs, elixir Instructions by
Ibuprofen (pain
Analgesic/
Naproxen (pain oral
reliever)
Robitussin (cough PO
Tinactin (anti-
Lotrimin (anti-
OTC lip balms
Pepto-Bismol
Kaopectate (anti- PO
Page 4 of 7
Camper Forms Packet
Please complete and return to:
Director of Programs
152 Madison Avenue, Suite 2400
New York, NY 10016
Camper's
Drug Name
(please circle
Schedule and
Health Care Comments
preferred
Indications
Provider
formulation(s))
Imodium (anti-
Mylanta (antacid) PO
Maalox (anti-gas- PO
Dramamine
Dimetapp
Povidone (iodine)
Listerine
ophthalmic)
Murine
ophthalmic)
Caldescene (zinc Powder
drying agents)
Bacitracin (anti-
Neosporin (anti-
Hydrocortisone Cream
Chlortrimeton
Emollient skin
(Undecylenic acid topically
antifungal)
Page 5 of 7
Camper Forms Packet
Please complete and return to:
Director of Programs
152 Madison Avenue, Suite 2400
New York, NY 10016
Camper's
Drug Name
(please circle
Schedule and
Health Care Comments
preferred
Indications
Provider
formulation(s))
RID(piperonyl
butoxide/pyrethrum topical
(permethrin)
Oxygen
½ teaspoon salt Gargle 1 minute q2 hrs. Saline gargle
Throat Lozenges oral Per
Cramergesic
ointment
Solar cream, Aloe Cream/gel
Vera Gel, Noxema (topical)
Chloraspectic
Caladryl
(Analgesic)
Sunscreen
Insect repellant Spray/oil (topical)
Epinephrine or
Benadryl
(Diphenhydramine (elixir, chewable tabs instructions by (hives, insect bite) 1 spray each nostril q12.5-25 mg Q 4-6 hr decongestant (not to exceed 3 days per use) Milk of Magnesia PO
Claritin tabs
Health Care Provider Name : ________________________ Address: _________________________________________________________________________ License number: __________________________________________________________________ Signature: _______________________________________
A doctor's signature is required in order for our medical staff to administer over-the-
counter products.
Page 6 of 7
Camper Forms Packet
Please complete and return to:
Director of Programs
152 Madison Avenue, Suite 2400
New York, NY 10016
CAMPER MEDICATION AUTHORIZATION
For Prescription Medication and Non-Prescription Medication All forms must be completed by a Physician!
To the Healthcare Provider: Please use this form for any prescription or over-the-counter
medication or vitamins that the Camper may need to take during the program season. Please use
one medication per page and make additional copies as required.

(Campers Name) is to receive the following medication Medication: ______________________________________________________________ Dosage: ________________________________________________________________ Hours to be given: ________________________________________________________ Diagnosis: _______________________________________________________________ Any special restrictions or unusual effects to be aware of: ________________________________________________________________________ ________________________________________________________________________ Please check if Camper is able to self-medicate on out off-campus trips: □ YES □ NO
Signature of licensed medical practitioner: __________________________ Date: ____________ Telephone: ______________________________ ______________________________ Cell Phone:_______________________
To be completed by parent/guardian

Please give the medication to ________________________(Campers Name) as directed by the physician.
Signature or parent/guardian: ___________________________ Date(month/date/year): ____________ Print Name: __________________________________________________ ***Please note, your child will not receive any of his/her prescription, over-the-counter or
vitamin supplements without this completed form***
Page 7 of 7
Camper Forms Packet

Source: http://www.lajf.org/userfiles/file/2012%20Medical%20Forms%20to%20be%20completed%20by%20Physician.pdf