Which Session is your camper going to? * Session 1 - July 28-August 3, 2024 Session 2 - August 4 - August 10, 2024 Camper Name * First Name Last Name Gender * Male Female Non-Binary Other Birth Date * MM DD YYYY Age on arrival at camp * Camper Home Address: * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/guardian with legal custody to be contacted in case of illness or injury: * First Name Last Name Relationship to Camper: * Preferred Phone #1 * (###) ### #### Preferred Phone #2 (###) ### #### Email * Additional contact in event parent(s)/guardian(s) cannot be reached: * First Name Last Name Relationship to Camper: * Preferred Phone #1 * (###) ### #### Preferred Phone #2 (###) ### #### Allergies: * No Known allergies This camper is allergic to Food This camper is allergic to Medicine The environment (insect stings, hay fever, etc) Other (Please describe below what the camper is allergic to and the reaction seen.) Diet, Nutrition: * This camper eats a regular diet This camper eats a regular vegetarian diet This camper is lactose intolerant This camper is gluten intolerant Other, please explain in space. Restrictions: * I have reviewed the program and activites 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 adaptations. (Please describe below.) Medical Insurance Information: (This camper is covered by family medical/hospital insurance) * Yes No Insurance Company Policy Number Subscriber Insurance Company Phone Number (###) ### #### Electronic Signature. You agrees that the electronic signatures, whether digital or encrypted, of the parties included in this Agreement, if any, are intended to authenticate this writing and to have the same force and effect as manual signatures * Date * MM DD YYYY Relationship to Camper: * Immunization History: Provide the month and year for each immunization. Starred (*) immunizations must include date to meet ACA Standard. Copies of immunization forms from health-care provider or state or local government are acceptable: please upload to this form. Diptheria, tetanus, pertussis (DTaP) or (TdaP) Dose 1 MM DD YYYY Dose 2 MM DD YYYY Dose 3 MM DD YYYY Dose 4 MM DD YYYY Dose 5 MM DD YYYY Tetanus booster * (dT) or (TdaP) Most Recent Dose MM DD YYYY Mumps, measles, rubella (MMR) Dose 1 MM DD YYYY Dose 2 MM DD YYYY Most Recent Dose MM DD YYYY Polio (IPV) Dose 1 MM DD YYYY Dose 2 MM DD YYYY Dose 3 MM DD YYYY Dose 4 MM DD YYYY Haemphilus influenzae type B (HIB) Dose 1 MM DD YYYY Dose 2 MM DD YYYY Dose 3 MM DD YYYY Dose 4 MM DD YYYY Pneumococcal (PCV) Dose 1 MM DD YYYY Dose 2 MM DD YYYY Dose 3 MM DD YYYY Dose 4 MM DD YYYY Hepatitis B Dose 1 MM DD YYYY Dose 2 MM DD YYYY Dose 3 MM DD YYYY Hepatitis A Dose 1 MM DD YYYY Dose 2 MM DD YYYY Varicella (Chicken Pox) Had chicken pox: enter date MM DD YYYY Dose 1 MM DD YYYY Dose 2 MM DD YYYY Meningococcal Menigitis (MCV4) Dose 1 MM DD YYYY Tuberculosis (TB) test Date MM DD YYYY Result Negative Positive 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. Electronic Signature. You agrees that the electronic signatures, whether digital or encrypted, of the parties included in this Agreement, if any, are intended to authenticate this writing and to have the same force and effect as manual signatures * Date MM DD YYYY Relationship to Camper: 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 review camp instruction about required packaging/containers. Many states require original pharmacy containers with labels which show the camper's name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp. Name of medication #1 Date started MM DD YYYY Reason for taking it When it is given Breakfast Lunch Dinner Bedtime Other time: If other time: explain here Amount or dose given How it is given Name of medication #2 Date started MM DD YYYY Reason for taking it When it is given Breakfast Lunch Dinner Bedtime Other time: Amount or dose given How it is given Name of medication #3 Date started MM DD YYYY Reason for taking it When it is given Breakfast Lunch Dinner Bedtime Other time: Amount or dose given How it is given Name of medication #4 Date started MM DD YYYY Reason for taking it When it is given Breakfast Lunch Dinner Bedtime Other time: Amount or dose given How it is given 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. CHECK all boxes the camper should NOT be given. Acetaminophen (Tylenol) Phenylephrine decongestant (Sudafed PE) Antihistamine/allergy medicine Diphenhydramine antihistamine/allergy medicine (Benadryl) Sore throat spray Lice Shampoo or cream (Nix or Elimite) Calamine Lotion Laxatives for constipation (Ex-Lax) Ibuprofen (Advil, Motrin) Pseudoephedrine decongestant (Sudafed) Guaifenesin cough syrup (Robitussin) Dextromethorphan cough syrup (Robitussin DM) Generic cough drops Antibiotic cream Aloe Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) General Health History: Check "Yes" or "No" for each statement. Explain "Yes" answers below. 1. Ever been hospitalized? Yes No 2. Ever had surgery? Yes No 3. Have recurrent/chronic illnesses? Yes No 4. Had a recent infectious disease? Yes No 5. Had a recent injury? Yes No 6. Had asthma/wheezing/shortness of breath? Yes No 7. Have diabetes? Yes No 8. Had seizures? Yes No 9. Had headaches? Yes No 10. Wear glasses, contacts, or protective eyewear? Yes No 11. Had fainting or dizziness? Yes No 12. Passed out/had chest pain during exercise? Yes No 13. Had mononucleosis ("mono") during the past 12 months? Yes No 14. If female, Have problems with periods/menstruation? Yes No 15. Have problems with falling asleep/sleepwalking? Yes No 16. Ever had back/joint problems? Yes No 17. Have a history of bedwetting? Yes No 18. Have problems with diarrhea/constipation? Yes No 19. Have any skin problems? Yes No 20. Traveled outside the country in the past 9 months? Yes No Please explain "Yes" answers in the space below, noting the number of the questions. For travel outside the country, please name the 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)? Yes No 2. Ever been treated for emotional or behavioral difficulties or an eating disorder? Yes No 3. During the past 12 months, seen a professional to address mental/emottional health concerns? Yes No 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) Yes No Please explain "Yes" answers in the space below, noting the number of the questions. The Camp may contact you for additional information. Health-Care Provider: Name of camper's primary doctor(s) Phone (###) ### #### Name of dentist(s) Phone (###) ### #### Name of orthodontist(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 importantor that may affect the camper's ability to fully participate in the camp program. Attach additional information if needed. Thank you! PHYSICIAN FORM - CLICK HERE Upload Signed Physician Here Upload Phycisian Form Thank you!
