Microsoft word - 2013 health form.docx

Lake Geneva Youth Camp – Health Certificate
This health form must be completed by the parent or legal guardian of the camper, and signed at the
bottom. This form must be returned to the Camp Nurse on or before registration time on the first day of
camp.
General Information
Camper Name________________________________Birthdate_________________Sex_____Age________ Home address________________________________City_____________________State______Zip_______ Home phone ___________________________Parent/Guardian name_______________________________ Parent/Guardian cell number______________________Parent/Guardian work number__________________ 2nd Parent/Guardian name_______________________________Home number________________________ Address___________________________________City_______________________State_______Zip______ 2nd Parent/Guardian cell number________________2nd Parent/Guardian work number__________________ In case of emergency contact:
Name____________________________________Phone number(s)________________________________ Name____________________________________Phone number(s)________________________________ Allergies
This camper is allergic to: ____Food; ____Medicine; ____The environment (insect stings, hay fever, etc.); ____Other. Please describe below what the camper is allergic to and the reaction seen. _______________________________________________________________________________________ _______________________________________________________________________________________ Restrictions
____I have reviewed the program and activities of the camp and feel the camper can participate without restrictions. ____I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions: ______________________________________________________________________________________ Medical Insurance Information
This camper is covered by family medical/hospital insurance. ____Yes ____No Insurance company_________________________________ Policy number_____________________________________ Subscriber________________________________________ Insurance Company Phone Number____________________ Immunizations
Are the camper’s immunizations up-to-date? ____Yes ____No If not, why not?_________________________________________________________________________ Medication
_____This camper will not take any medications while attending camp. _____This camper will take the following medication(s) while at camp: If change/addition of medication(s) before arrival at camp, please see Nurse at registration to make
necessary changes.
“Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins
& natural remedies. Please send medications in their original pharmacy container with labels which
show the camper’s name and how the medication should be given. Provide enough of each medication
to last the entire time the camper will be at camp.
Name of Medication_____________________________________ Reason for taking it?______________________________________ When is it given? ____Breakfast; ____Lunch; _____Dinner; _____Bedtime: _____Other Time Amount or dose given ___________________________________ How is it given?_________________________________________ Name of Medication_____________________________________ Reason for taking it?______________________________________ When is it given? ____Breakfast; ____Lunch; _____Dinner; _____Bedtime: _____Other Time Amount or dose given ___________________________________ How is it given?_________________________________________ Name of Medication_____________________________________ Reason for taking it?______________________________________ When is it given? ____Breakfast; ____Lunch; _____Dinner; _____Bedtime: _____Other Time Amount or dose given ___________________________________ How is it given?_________________________________________ The following non-prescription medications may be stocked in the camp Nurse’s station and are used on an
as needed basis to manage illness and injury. Check those the camper should NOT be given:
____Diphenhydramine antihistamine/allergy medicine ____Phenylephrine decongestant (Sudafed PE) ____Lice shampoo or cream (Nix or Elimite) ____Guaifenesin cough syrup (Robitussin) ____Dextromethorphan cough syrup (Robitussin DM) ____Bismuth subsalicylate for diarrhea (Kaopectate, Pepto Bismol) General Health History
Check “Yes” or “No” for each statement. Explain “Yes” answers below. Has/does the camper:
Had asthma/wheezing/shortness of breath? Passed out/had chest pain during exercise? Had mononucleosis (“mono”) during past 12 months? If female, have problems with periods/menstruation? Have problems with diarrhea/constipation? Have problems with falling asleep/sleepwalking? Traveled outside the country in the past 9 months? Please explain “Yes” answers below, noting the number of the question. For travel outside the country, please name countries visited and dates of travel._______________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Mental, Emotional, and Social Health
Check “Yes” or “No” for each statement. Has the camper:
Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)? ___Yes ___No Ever been treated for emotional or behavioral difficulties or an eating disorder? ____Yes ____No During the past 12 months, seen a professional to address mental/emotional health concerns? ____Yes ____No Had a significant life event that continues to affect the camper’s life? (History of abuse, death of a loved one, family change, adoption, fosgter care, new sibling, survived a disaster, others) ____Yes ____No Please explain “Yes” answers below, noting the number of the questions. The camp may contact you for additional information._____________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Health Care Providers
Name of camper’s primary doctor___________________________________________ Phone_____________________________________ Name of dentist_________________________________________________________ Phone____________________________________ Name of orthodontist_____________________________________________________ What have we forgotten to ask?
Please provide 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. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Parent Signature

Source: http://www.lgyc.org/wp-content/uploads/2013/05/Health-Form.pdf