Catskill camp services, inc

Team Number________________ Team Name_______________________________ Week #_____ Cooperstown Dreams Park Medical Services
Camper Information
This side to be completed by parent or guardian:
Child:
Last Name _____________________First Name_________________ Sex____ DOB_______
Address_____________________________________________________________________
Parent:
Last Name __________________ First Name ___________________ Home Phone___________
Address__________________________________________________ Cell Phone ____________
Second Contact:
Last Name __________________ First Name ___________________ Home Phone___________
Address__________________________________________________ Cell Phone ___________
Relationship _____________________________________________ Work Phone___________
If parent / guardian is coming to Cooperstown where are they staying:
__________________________________________________________Phone #______________

Health History:
Yes
Allergies
Please list ____________________________________ Diabetes
Seizure disorder
Heart Disease Please explain__________________________________
Other History Please explain__________________________________

Immunization History: Most recent date of immunization
MMR ___/___/___
Hepatitis B Series completed ___/___/___ Haemophilus Influenza Type b ___/___/___ Chicken Pox (Varicella) vaccine date ___/___/___ or Disease date___/___/__ A copy of immunization history is acceptable. Please attach a photocopy of your camper’s insurance card. IMPORTANT – THIS CONSENT MUST BE COMPLETED FOR ATTENDANCE
This health history is correct to the best of my knowledge, and the person herein described has permission to engage in all camp activities except as specifically noted. In the event of serious illness or injury, I hereby give Catskill Camp Services Inc. permission to provide emergency treatment and referral to a hospital in the event I cannot be reached. I give permission to the physician selected by the camp Health Director to hospitalize, secure proper treatment for, and to provide anesthesia, pain control, and/or other invasive treatments in the event of severe illness or injury for my child as named above. I also give permission for my child’s personal, protected medical information provided on this form, and any personal protected health information collected by personnel of Catskill Camp Services Inc. to be released to any hospital and/or clinic providing treatment, Cooperstown Dreams Park management and any insurance company representing Cooperstown Dreams Park. This form may be photocopied for use out of camp. Signature of parent/ guardian______________________________________ Cooperstown Dreams Park Medical Services
Camper Examination and Medications
Camper’s Name_________________________________ Date of Birth___________ Team Name ___________________________________ This form is to be completed by a Physician, Physician Assistant or Nurse Practitioner.
I examined this individual on __________ (must be within 12 months from the start of camp). In my opinion, the above camper  is  is not able to participate in an active camp program. The camper is under the care of a physician for the following conditions: _____________________________________________________________________ Treatments to be continued at Camp: __________________________________________ ________________________________________________________________________ Medications: New York State Department of Health requires that camps have an individualized set of standing orders for each camper attending camp. The list below is of the standard over the counter medications campers may require while at camp. The medications will only be administered at the discretion of a Registered Professional Nurse. A licensed health care provider needs to initial in the Yes box if they wish the child to be eligible to receive the medication at camp and sign the bottom of this form.  Yes  No Acetaminophen PO per label instructions by age/weight every four hours as  Yes  No Ibuprofen PO per label instructions by age/weight every 6 hours as needed for  Yes  No Diphenhydramine PO per label instructions by age/weight every 4-6 hours as  Yes  No Mylanta PO per label instructions by age/weight three to four times a day as  Yes  No Dimetapp PO per label instructions by age/weight every 6-8 hours as needed for  Yes  No Robitussin PO per label instructions by age/weight every 4 hours as needed for Daily/ Prescribed Medications and PRN medications the child will need while at camp.
All Medications Must be in the original containers.
Health Care Providers Name: _______________________________ Phone #_________ Address_______________________________________ License # _________________ Health Care Providers Signature _____________________________ Date ___________ Provider and/or practice stamp:

Source: http://billyjameson.net/files/2013_Ctown_CampHealthHistoryandExamination_12.10.12_C.pdf