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Bfsc day camp health form-2013

Camper Health Form
P.O.  Box  1513  Cherry  Hil ,  NJ   08034   www.barclayfarm.org  

Mail or

BFSC Day Camp
Email: CampOffice@barclayfarm.org
c/o Chris Shull
120 Deerfield Drive
Fax: (567) 429-6052
Cherry Hill, NJ 08034

Child’s Name: ______________________________________, Date of Birth: ____________________
Address: __________________________________________________________________________
Parent or Guardians: __________________________ (#1); ____________________________ (#2)
Home Phone: _________________________ (#1); ____________________________ (#2) Work Phone: __________________________ (#1); ____________________________ (#2) Cell Phone: ___________________________ (#1); ____________________________ (#2) In an emergency notify: ____________________________ Relationship to Child: _________________ Address: __________________________________________________________________________ Phones Home#: __________________; Work#: __________________; Cell #: __________________ Does child have physical, medical or emotional problems?  Yes  No If yes, please describe: __________________________________________________________________________________ Does your child take any medications on a daily basis?  Yes  No If yes, list medications: __________________________________________________________________________________ Does your child have any known allergic reactions to the following?  Bee Sting  Peanuts  Chocolate  Penicillin  Other Foods  Other Drugs  Seasonal Allergens  Other What is your child’s usual reaction?  Hives  Rash  Anaphylaxis  Other Please describe other: _______________________________________________________________ The Camp Directors have permission to administer Benadryl if needed for nonspecific rashes or minor allergic reactions?  Yes  No (Dosage based on child’s age or weight.) The Camp Directors have permission to administer the following for headaches or minor discomforts? HEALTH HISTORY: (Please check – giving appropriate dates.)
 Frequent Colds __________________________  Kidney Trouble _________________________  Chicken Pox ____________________________  Frequent Sore Throats ___________________  Measles _______________________________  Tuberculosis ___________________________  Bronchitis _______________________________  Mumps _______________________________  Heart Trouble ___________________________  Whooping Cough _______________________  Sinusitis _______________________________  Constipation ___________________________  Abscessed Ears _________________________  Convulsions ___________________________  Poliomyelitis ____________________________  Diabetes ______________________________  Athlete’s Foot ___________________________  Stomach Upsets ________________________  Serious Ivy, Oak, Sumac Poisoning _________________________ _________________________  Operations or Serious Injuries_________________________ ______________________________  Any Allergies_________________________ ___________________________________________ Emotional Stability:  Much  Some  Little  None _____________________________________ Maturity:  Much  Some  Little  None ______________________________________________ Any Personal Problems:  Much  Some  Little  None __________________________________ Any Behavior Problems: Explain _______________________________________________________ Any Learning Problems: Explain _______________________________________________________ Recommendations/Restrictions (diet, medicine, swimming, running, etc.) _______________________ _________________________________________________________________________________ _______________________________________________________________________________________________________________ IMMUNIZATIONS: (Write approx. date of immunization.) DPT Series Tetanus _________________________
Polio Measles (MMR) _______________________ Haemphilis (Hib) __________________________ Is child up to date with Tetanus vaccine or Tetanus booster shot?  Yes  No
In case of emergency, I understand every effort will be made to contact parents/guardian of camper. In
the event that I cannot be reached, I hereby give permission to the physician selected by the Director to
hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child, as
named above.
Parent Signature: ___________________________ Date: ______________________________
Physician’s Name: __________________________ Physician’s Phone: ___________________
Physician’s Signature: ______________________ Date of Last Physical: _________________

Medical exam is preferred but not required by state law. Doctor’s signature is only
necessary if camper requires medical clearance to participate in camp activities.
2013 Page 2 of 2

Source: https://barclayfarm.org/cms/wp-content/uploads/2011/03/BFSC-Day-Camp-Health-Form-2013.pdf

05 quinto vol -1965

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