HEALTH FORM
UNITED 4 KIDZZ – SUMMER CAMP 2016
*COMPLETED FORM MUST BE TURNED INTO YOUR CHURCH CONTACT PERSON BY JULY 24th
MUST be completed by Parent or Guardian. To ensure that your child stays safe and is provided with the best care possible PLEASE complete the entire form and provide any additional information that would be helpful.
Name of Camper ______Date of Birth______
LastFirstMiddle
Home Address______
Street AddressCityStateZip
Home Phone Number ______Gender___ Male ___Female
Age at time of camp ______Grade completed at time of camp_____
Name of Camper’s Father or Guardian ______
LastFirst
Name of Camper’s Mother or Guardian ______
LastFirst
Name of Emergency Contact: ______Phone Number ______
If not available, notify ______Phone Number ______
NOTE – MUST have medical coverage to attend camp.
Name of Health Insurance Company ______
Policy Number ______Name of Insured ______
GENERAL HEALTH QUESTIONS
Has/does your childYesNoYesNo
Had any recent injury, illness or infectious disease?______Have any skin problems?______
Have chronic or recurring illness/condition?______Have diabetes?______
Ever been hospitalized?______Have asthma?______
Ever had surgery?______Have frequent headaches?______
Had mononucleosis in the past 12 months?______Ever had seizures?______
Wear glasses, contacts or protective eye wear?______Have history of bed-wetting?______
Ever been dizzy or passed out during or after exercise?______Ever had hearing problems?______
Had problems with diarrhea/constipation?______Ever had kidney problems?______
Ever been diagnosed with heart problems?______
Please explain any “yes” answer: ______
______
Please state additional information that the Camp Nurse/Staff should be aware of: ______
______
Does your child have Emotional, Behavioral and/or Learning Challenges? If so, explain. Also state if your child is under the care of a Social Worker, Psychologist, Behavioral Therapist, etc. ______
______
______
IMMUNIZATION RECORD
All immunizations up-to-date?___ Yes___ No Explain why ______
______
State the date your child received a tetanus booster. ______
ALLERGIES List all known.Describe reaction and management of the reaction.
Medication allergies
______
______
Food allergies
______
______
Other allergies – include insect stings, hay fever, asthma, animal dander, etc.
______
RESTRICTIONS
Food restrictions (please write None if there are no food restrictions ______
Activity restrictions (please write NONE if there are no activity restrictions) ______
MEDICATION- ALL medications, prescribed and Over-the-Counter MUST be turned into the Camp Nurse The Camp Nurse will be dispensing Over-the-Counter products as needed (such as Tylenol, cough drops, etc.).
LISTOver-the-Counter products your child should NOT have______
LIST ALL Over-the-Counter products your child will be bringing and state under what conditions your child should receive these products.
Over-the-Counter Product ______
Given ______
Over-the-Counter Product ______
Given ______
Parent/Guardian Authorization: I hereby give permission to the authorized camp staff to provide routine health care, administer prescribed medications and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for insurance purposes. I give permission to the camp to arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the authorized camp staff to secure and administer treatment, including hospitalization, for the person named on this form.
Signature of parent/guardian ______Date ______
______
**The following section MUST be completed by a physician if your child has prescription medication that he/she will be taking during camp.
PRESCRIPTION MEDICATION LIST each prescription medication and complete instructions thischild will be bringing to camp.
Name of Medication / How should the medication be given? / How often should the medication be given? / Any additional instruction regarding the medication?Condition when the Physician should be contacted: ______
Physicians Signature ______Date ______
Physicians Phone Number ______
CONFIDENTIAL INFORMATION FOR CAMP COUNSELOR
UNITED 4 KIDZZ – SUMMER CAMP 2016
MUST be completed by Parent or Guardian. To ensure that this child receives the care and attention needed, PLEASE complete the following information that will be used by this child’s Camp Counselors.
Name of Camper ______Date of Birth______
LastFirstMiddle
Home Address ______
Street AddressCityStateZip
Age at time of camp ______Grade Completed ______
Food or activity restrictions? ______
______
ADDITIONAL INFORMATION
Has your child been away from home more than two days? ___ Yes___ No
Does your child take a while to make friends? ___ Yes___ No __ Sometimes
Finishes what he/she starts?___ Always___ Most of the time___ Rarely
Listens to instructions?___ Always___ Most of the time___ Rarely
Participates in team work?___ Always___ Most of the time___ Rarely
Is moody?___ Always___ Most of the time___ Rarely
Tends to take on leadership roles?___ Always___ Most of the time___ Rarely
Tends to have a positive attitude?___ Always___ Most of the time___ Rarely
Tends to tease others?___ Always___ Most of the time___ Rarely
Tends to obey rules?___ Always___ Most of the time___ Rarely
Sleep habits:___ Light sleeper ___ Heavy sleeper ___ Bed wetter ___ Sleepwalker ___ Nightmares
Child’s responsibilities at home ______
What experiences would you like your child to have at camp? ______
______
What does your child want to receive from his/her camp experience?______
______
If your child becomes upset, what are ways to help your child calm down? ______
______
What other information would you like the Senior Camp Counselor to know to help your child adjust to camp? ______
______
STATE WHO will be picking up your child from camp ______
LIST ANYONE THAT IS LEGALLY RESTRICTED from having contact with your child ______