Health Record for Camp Participation
North Carolina United Methodist Outdoor and Camping Ministries
*Please complete this form prior to arriving at camp. It will be required during the check in process on the day of arrival. Do not mail this to the camp or to the camp registrar (unless you are participating in the express check-in program-see information letter)
*Page 1 (Health Record for Camp Participation) and page 2 (Health History) may be completed by the parent or guardian.
*If the camper will need to bring medication(s) to camp to be administered, please read Page 3 (Camper Health Services: Medicine) and have your physician complete Page 4 (Request for Medication to be Given During Camp Session). Parent or guardian must sign at the bottom of Page 4 giving permission for the camper to received medications during camp.
Camper Name_________________________ Date of Birth______Social Security #___________
Parent/Guardian_________________________________________________________________
Home Address ___________________________________Phone ( )______________
Work Address ___________________________________Phone ( )______________
Second Parent__________________________________________________________________
Home Address ___________________________________Phone ( )______________
Work Address ___________________________________Phone ( )______________
Other Emergency Contact_________________________________________________________
Home Address ___________________________________Phone ( )______________
Name of Family Physician________________________________Phone ( )______________
Name of Dentist/Orthodontist _____________________________ Phone ( ) ______________
Is camper covered by family medical/hospital insurance? Yes_______ No________
If so, indicate Carrier______________________ Policy or group #_________________
Participation Requests or Limitations
Please indicate any pertinent information or requests regarding medical conditions, which may limit or alter participation. Information regarding medications can be found on Pages 3 & 4.
Activity restrictions:
Dietary restrictions:
Medical treatments:
Health History
Immunizations:
Were immunizations completed prior to entrance to school? Yes______ No _______
Month/year of last tetanus immunization (DPT, DT, T) ____________________
Yes/No Has Camper Had Any? Yes No Does Camper?
___/___ Chronic or recurrent illness ___ ___ Wear glasses/contacts
___/___ illness lasting over one week ___ ___ Wear dental braces/appliances
___/___ Hospitalizations ___ ___ Take regualr medications
___/___ Surgery ___ ___ Have Allergies to medications
___/___ Missing organs ___ ___ Have environmental allergies
___/___ Orthopedic injury/abnormality ___ ___ Have insect allergy
___ /___ Problems with heart or blood pressure ___ ___ React strongly to poison ivy
___/___ Chest pain with exercise ___ ___ Have asthma or recurrent
respiratory illness
___/___ Dizziness or fainting with exercise
___/___ Have intolerance to strenuous exercise
___/___ Frequent Headaches
___/___ Have a family member who died at less than 40 years of age due to non-accidental causes
___/___ Convulsions
___/___ have a family member of less than
55 whom has had a heart attack
___/___ Concussions or unconsciousness
___/___ Have emotional problems
___/___ Heat exhaustion, heat stroke, or problems with heat
___/___ Have behavioral problems ___ ___ Have bed wetting problem
___/___ Sleepwalking
(For Female) Has this person Menstruated? Yes __ No __ If not, has she been told about it? Yes _ No __
Use this space to explain any "YES" answers above or to provide any-additional information
This health record is correct as far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted.
EMERGENCY AUTHORIZATION:
I hereby give my permission to the medical personnel selected by the camp director to order x-rays, routine tests, and routine treatment for me/my child, an in the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injections, anesthesia or surgery for me/my child a s named above. This form may be photocopied for use out of camp.
Signature of parent/guardian, or adult camper/staff: _________________________ Date __________
I will participate in the activities, follow the rules, cooperate with the Rockfish Staff and be a faithful member of the Rockfish community. “I agree not to bring: electronic games or devices of any kind, food, weapons, or illegal drugs.”
Signature of minor: ____________________________________________________ Date:___________
___________________________________________________________________________________
Medication Brought: Must be accompanied by "Request for Medication" form (page 4)
Camp review of form by ___________________________________________Date ____________
Camper Health Services: Medicines
• The parent will obtain a copy of the form "Request for Medication to be Given During Camp Session." This form must be completed and signed by the physician and signed by the parent. This from is valid for the duration of the camp session unless a shorter duration is indicated. This form is required for all medications, both prescription and over-the-counter ( i.e. tylenol, aspirin, cough medicines ). Over-the- counter medications, in general, are available at the camp Health Services and do not need to be sent to camp. Only one medication may be listed on each form. Any changes require a new form to be completed.
• The parent will bring the medication and the completed and signed form to camp. Prescription medications must be in a pharmacy labeled container which includes instructions on how and when the medication is to be given. Over-the-counter medications must be in original container and will be administered according to the physician's written instructions.
• Once the parent has complied with numbers 1 and 2 of these procedures, the camp will ensure that the camper receives the medication as prescribed by a physician.
• The camp will store the medication in a locked container.
• The camp director will designate personnel in the camp to have primary responsibilty for the medication and the administration ( usually the the Health Coordinator or Nurse )
• Each time a medication is to be given, the designated person will check the Medication Log and the medication label for the " 5 R's ":
• Right person
• Right medication
• Right time
• Right dose
• Right route of administration ( i.e. oral-by mouth, topical-on the skin, etc. )
• Medications will remain in the locked container and in their individual containers until the camper presents him/herself for the medication.
• The person responsible for administering the medication must observe the camper as he or she takes the medication.
• The camp will maintain a Medication Log with the date, time, the amount taken, and the initials of the person administering the medication each time it is given.
• The parent will arrange for the proper removal of medication from the camp after it is discontinued. Any medication left at the camp at the end of the session will be disposed of by the camp personnel. A notation will be made in the medication log when a medication is discontinued ( either by physician's order or by exhaustion of the medication supply ) and also when a medication is disposed of at the end of the camp session.
• Campers with asthma will be permitted to have in their possession prescribed inhaled medications for the prevention and treatment of asthma symptoms as long as the following requirements are met:
• The camper's physician prescribes the inhaled medication and states in writing that the camper has sufficient knowledge and maturity to use the inhaled medication correctly.
• The parent/guardian states in writing that the camper has sufficient knowledge and maturity to use the inhaled medication correctly and releases the camp and is personnel from any responsibility regarding the medication.
• The camper complies with the following:
• The camper will keep the inhaled medication in his/her possession at all times and and shall not leave it in a place accessible to other campers.
• The camper will not offer, nor allow, any use or possession of his/her inhaled medication by another camper.
• The camper will act in a responsible and discreet manner concerning his/her inhaled medication at all times.
• If asthma symptoms should occur during required physical activity, the camper will use his/her inhaler as needed and inform the staff member who is in charge.
Request for Medication to be Given During Camp Session
Name of Camper________________________________________ Camp________________
#1 Medication ________________________________________Dosage____________________
Time(s) to be given________________________________________________________
To be given from (date) ____________________________________________________
Significant information (include side effects, toxic reactions, omission reactions)
Contraindication for Administration:
#2 Medication ________________________________________Dosage____________________
Time(s) to be given________________________________________________________
To be given from (date) ____________________________________________________
Significant information (include side effects, toxic reactions, omission reactions)
Contraindication for Administration:
#3 Medication ________________________________________Dosage____________________
Time(s) to be given________________________________________________________
To be given from (date) ____________________________________________________
Significant information (include side effects, toxic reactions, omission reactions)
Contraindication for Administration:
This medication will be furnished by parent or guardian in a container properly labeled by a pharmacist with identifying information (e.g. the name of the child, medication dispensed, dosage require, and the time it is to be given)
Physicians Signature __________________________________Date___________DEA#______________
______________________________________________________________________________________
Parents Permission:
I hereby give my permission for my child (named above) to receive medication during camp. This medication has been prescribed by a licensed physician. I hereby release the camp and their agents/employees from any and all liability that may result from my child taking the prescribed medication.
Parent/Guardian Signature _______________________________Date__________Phone #___________
_____________________________________________________________________________________
~ Camp Use Only ~
Name and title of person to administer medication _______________________________________________
Approved by_______________________________________ Date________________________________