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CampSession attendingCabin assignment

CAMP TRINITY 2014

P. O. Drawer 380

Salter Path, NC28575

CAMPER'S NAME______Birthdate______Sex______Age______

Parent/Guardian______

Home Address______City______State____Zipcode______

Phone: Day (____)______Night (____)______Mother Cell(____)______Father Cell (____)______

Vacation address(if applicable)______City______State____Zipcode ______

Phone: (____)______Dates: ______

Emergency Contact:

Name______Relationship______Phone: (____)______

If this person is not available in an Emergency, please notify:

Name/relationship______Phone: (____)______

Primary Care:

Name of camper’s Physician and Phone ______

Name of camper’s Dentist and Phone ______

Health History: (Indicate with approximate dates)

Ear Infections______Asthma______Convulsions______Diabetes______Hearth defects/disease______Mononucleosis_____

Diseases:

Measles______German Measles______Chicken Pox______Mumps______Other______

Allergies:

Hay Fever______Ivy Poisoning______Insect bites/stings______Penicillin______Sulfa______

Other (specify) ______

Other:

Disabilities, chronic or recurring illness: ______

Operations or Serious Injuries (include dates): ______

Mental of physical problems: ______

Dietary Modifications: ______

Problems with bed-wetting/comments: ______

Has this person presently or previously undergone psychiatric and/or substance abuse treatment of any type?

Explain:______

For Females Only:

Has this person menstruated? ______If no, has she been told about it?______

Is her history normal?______Special Considerations ______

Parents comments and suggestions: (activities to be encouraged/restricted, special concerns and explanations)

Camper:______

MEDICAL EXAMINATION: TO BE COMPLETED BY A LICENSED PHYSICIAN

PLEASE NOTE: A health history/examination form must be completed and sent intothe camp office EACHYEAR by a parent or guardian30 days before admission to a camp session.

A physician's examination for some other purpose within the past year is acceptable if the information requested on that form is the same as for this request. Examination is necessary in case of illness or accident and to determine fitness to engage in all camp activities

IMMUNIZATION HISTORY: (Dates of basic immunizations/most recent booster doses)

DTP/DTaP ______Booster ______MMR______

Td/TDAP ______Booster ______Tuberculin Test______

Polio Series______Booster ______Varicella (disease)______vaccine ______

Hep B Series ______Hep A______Menactra ______

GENERAL APPRAISAL:

Height ______Weight______BP ______

Eyes______Glasses/contacts______Nose ______

Teeth______Braces______Throat ______

Ears ______Heart ______

Speech______Hearing______Lungs ______

RECOMMENDATIONS AND RESTRICTIONS WHILE AT CAMP:

The applicant is under the care of a physician for the following condition(s):______

______

Current treatment to be continued at camp______

______

Specific medications: prescription and OTC, to be administered at camp______

______

Swimming/Diving ______

Strenuous activity (describe)______

Dietary restrictions______

Allergies(food, drugs, plant, insect)______

Additional health information______

______

Licensed Physician's Signature

I have examined the person described herein and have reviewed his/her health history. It is my opinion that he/she is physically able to engage in camp activities, except as noted above.

______

Signature of Examining Physician*(Please print or type name)

(____)______-______

TelephoneCityStateZip

Date form completed______*By______

*Initial if completed by nurse or physician's assistant

A note to parents: Please notify the camp nurse at check - in if the camper has been exposed to or exhibits any symptoms of a communicable disease during the three weeks prior to camp attendance. Do not bring a sick child to camp. We reserve the right to send campers home who are sick on arrival.