2011healthform

Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Mail this form to the address below at least two weeks prior to the start of your camp. Parent/guardian with legal custody to be contacted in case of illness or injury: Second parent/guardian or other emergency contact: Additional contact in event parent(s)/guardian(s) can not be reached: Allergies:
The environment (insect stings, hay fever, etc.) (Please describe below what the camper is allergic to and the reaction seen.) Diet, Nutrition:
This camper eats a regular vegetarian diet. This camper has special food needs. (Please describe below.) 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 or Medical Insurance Information:
This camper is covered by family medical/hospital insurance Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable. Parent/Guardian Authorization for Health Care:
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in
all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests,
and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my
permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on
this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a
copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.
If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Immunizations
This camper is current with all immunizations If your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being
fully immunized.
Medication:
This camper will not take any daily medications while attending camp. This camper will take the following daily medication(s) while at camp: "Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Please bring original pharmacy containers with labels for prescription medication which show the camper’s name and how the medication should be given. All over the counter medication must be labeled with campers name and instructions for use. Provide enough of each medication to last the entire time the camper will be at camp. The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Cross out those the camper should Diphenhydramine antihistamine/allergy medicine (Benadryl) Dextromethorphan cough syrup (Robitussin DM) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Copyright 2008 by American Camping Association, Inc. Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses General Health History: Check "Yes" or "No" for each statement. Explain “Yes” answers below.
1. Ever been hospitalized? …………………………. 12. Passed out/had chest pain during exercise? ….……………. 3. Have recurrent/chronic illnesses? .……….… 13. Had mononucleosis ("mono") during the past 12 months?. 4. Had a recent infectious disease? . …………. 14. If female, have problems with periods/menstruation?.……. 15. Have problems with falling asleep/sleepwalking? . 6. Had asthma/wheezing/shortness of breath?. 16. Ever had back/joint problems?…….……….……………. 17. Have a history of bedwetting?………………….……………. 18. Have problems with diarrhea/constipation?………………. 9. Had headaches? …………………………………. 19. Have any skin problems?……………………. 10. Wear glasses, contacts, or protective eyewear? 20. Traveled outside the country in the past 9 months?. Please explain “Yes” answers in the space below, noting the number of the questions. 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.
1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)? ………………………. 2. Ever been treated for emotional or behavioral difficulties or an eating disorder?……. 3. During the past 12 months, seen a professional to address mental/emotional health concerns?……….…………………………………. 4. Had a significant life event that continues to affect the camper’s life?. (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others) Please explain “Yes” answers in the space below, noting the number of the questions. The camp may contact you for additional information. Health-Care Providers:
Name of camper’s primary doctor(s): Phone: ( _) What Have We Forgotten to Ask? Please provide in the space below 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. Attach additional information if needed.
Copyright 2008 by American Camping Association, Inc. BLUE LAKE UNITED METHODIST ASSEMBLY, INC.
AGREEMENT TO PARTICIPATE; ASSUMPTION OF RISK AND RELEASE OF LIABILITY
WHEREAS, THE UNDERSIGNED PARENT OR GUARDIAN wishes to have their child be accepted for participation in the Blue Lake The undersigned acknowledge(s) that during the said Blue Lake United Methodist Assembly program for 2013 Summer Camp
that their child or person(s), for whom they have responsibility, has requested to participate in, that certain risks and dangers may occur. These include, but are not limited to hazards of traveling wooded terrain, ropes course, using water borne craft such a canoe, accident or illness in a remote place with medical facilities eighteen (18) miles away, and travel by various conveyance. The undersigned further recognizes that these risks may also include loss or damage to personal property, physical or psychological damage and/or injury not excluding fatality due to accidents which may occur, including accidents resulting from other types of outdoor activities. I further understand that in allowing my child or the person to whom I have responsibility to participate in camping activities he/she will be exposed to the elements of nature, including temperature extremes, and inclement weather. I further understand that medical treatment may be several minutes to an hour away in the I certify that my child or the person for whom I am responsible for, is healthy enough (both physically and emotionally) and capable of participating in this Blue Lake United Methodist Assembly program. I have listed on the Health Form any medical conditions that Blue Lake United Methodist Assembly, Inc., should be aware of which may hinder my child, or the person for whom I am responsible for, from participating in any particular activity. However, I understand that it is solely my parental or
guardian responsibility to determine whether there is any medical reason that my child or the person for which I am
responsible for, should not participate in the Summer Camping Program at Blue Lake United Methodist Assembly, Inc.
In consideration of, and as part payment for the right to participate in such a camping program and the services and food arranged for my child or person for whom I am responsible for, by Blue Lake United Methodist Assembly, Inc., Directors, Officers, Employees, Agents, and/or Associates I have and do hereby assume all the above risk and any other ordinary risk incidental to the nature of the Blue Lake United Methodist Assembly program which is not specifically foreseeable, and will hold them harmless from any and all liability, actions, causes of action, debts, claims and demands of every kind and nature whatsoever, whether from bodily injury, property damage or loss or otherwise, which I now have or which may arise from or in connection with by camp or participation in any other activities arranged for me by Blue Lake United Methodist Assembly, Inc., its Directors, Officers, Employees, Agents and/or Associates, and their heirs, executors and administrators, successors and assigns and for all members of my family, including any minors accompanying me. In short, I cannot sue Blue Lake United Methodist Assembly, Inc., and if I do, I cannot collect any money. In addition, I will be liable for Attorney and Court fees associated with any litigation against Blue Lake United Methodist Assembly, Inc. I also state that my child or the person for whom I am responsible for, nor I, am not under, and wil not be under the influence of any chemical substance including alcohol. I fully understand that my child’s, and/or the child for whom I have responsibility for, physical activity involves risk of injury. I also understand that my child’s or person for whom I have responsibility for, participation in Blue Lake United Methodist Assembly, Inc., program is entirely VOLUNTARY. I enter my child, or the person for whom I have responsibility for, enter into this Blue Lake United Methodist Assembly, Inc., program and take full responsibility for my decision for him/her to participate or not to participate and agree to follow all safety instructions. Name of Participant (print) ______________________ Name of Parent/Guardian (print)_________________________
Date of Signature for Parent/Guardian ________ Signature of Parent/Guardian____________________________ Signature of Witness___________________________________

Source: http://www.dumaswesley.org/wp-content/uploads/2013/04/Blue-Lake-Health-Forms.pdf