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Microsoft word - k-w_camper-health-history-form-1.doc

Kieve-Wavus Education, Inc.
CAMPER HEALTH HISTORY FORM 1
Dates will attend camp: _____/_____/_____ to _____/_____/_____ Month Day Year Month Day Year Camper Name: _______________________________________________________________________ c/o Liz Jones
F Birth Date: _____/_____/_____ Age on arrival at camp _________ Kieve-Wavus Education, Inc.
Month Day Year Social Security Number _________ - ________ - ____________________ P.O. Box 350
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Jefferson, ME 04348
To Parents(s)/Guardian(s): Please follow the instructions below. Attach additional information if needed. Complete pages 1, 2, and 3 of this form (FORM 1) and make a copy. Be sure to include an Questions?
Send the original, signed FORM 1 and copies of your current insurance card to camp. Complete the top of FORM 2 (CAMPER HEALTH-CARE RECOMMENDATIONS) and provide the copy of FORM 1 with FORM 2 to your child’s health-care provider for review and completion. After it has been completed and signed by your child’s health care provider, return FORM 2. Camper Home Address: ___________________________________________________________________________________________________ Parent/guardian with legal custody to be contacted in case of illness or injury: Relationship Preferred (______) __________________________ Name ___________________________________________ to Camper _______________Phones (______) __________________________ Email _____________________________________________ (______) ___________________________ Home Address ________________________________________________________________________________________________________ (If different from above) Street Address City State Zip Code Second parent/guardian or other emergency contact: Relationship Preferred (______) __________________________ Name ___________________________________________ to Camper _______________Phones (______) __________________________ Email _____________________________________________ (______) ___________________________ Additional contact in event parent(s)/guardian(s) cannot be reached: Relationship Preferred (______) __________________________ Name ___________________________________________ to Camper _______________Phones (______) __________________________ Email _____________________________________________ (______) ___________________________ Allergies: No known allergies This camper is allergic to Food 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 has special food needs (Please describe below – attach additional information if necessary)
Restrictions: I have reviewed the program and activities 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 or on reverse side of this form)
Medical Insurance Information: This camper is covered by family medical/hospital insurance Yes No
INCLUDE A COPY OF YOUR INSURANCE CARD IF APPROPRIATE. PLEASE COPY BOTH SIDES OF THE CARD SO INFORMATION IS READABLE.
Subscriber Name: __________________________________________ Insurance Company: ________________________________________
Subscriber’s Employer: _____________________________________ Policy Number: _____________________________________________
Subscriber’s DOB ________/________/___________ Insurance Company Phone Number: (______) __________________

Subscriber’s SSN
________ - _______ - ________________ Primary Care Physician:____________________________________
Parent/Guardian Authorization for Health Care:
This form is correct and accurately reflects the health status of the child. The child has permission to
participate in all Kieve-Wavus activities except as noted by me and/or an examining physician. I authorize the Kieve-Wavus staff to provide routine healthcare, dispense medications, and seek emergency treatment for the child. I give permission to the physician selected by Kieve-Wavus to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to hospitalize, secure proper treatment for, and order injection, anesthesia or surgery for the child. I understand the information on this form will be shared on a “need to know” basis with Kieve-Wavus staff. I give permission to photocopy this form. In addition Kieve-Wavus has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status. Kieve-Wavus is not responsible for any medical costs incurred on behalf of the child. _________________________________________________________________ _____/_____/______ _________________________________________ Signature of Custodial Parent/Guardian Date Relationship to Camper If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance. CAMPER HEALTH HISTORY FORM 1
Camper Name _________________________________________ Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Birth Date _____/_____/_______ Month Day Year Immunization History: Provide the month & year for immunizations. Starred (*) immunizations must be current. Copies of immunization
forms from health-care providers or state or local government are acceptable; please attach to this form.
Most Recent Dose
(dT) or (TdaP) Mumps, measles, rubella * 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.
_________________________________________________________________ _____/_____/______ _________________________________________
Signature or Custodial Parent/Guardian Date Relationship to Camper
Medication: “Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Please
send all medication in original packaging and provide enough of each medication to last the entire time the camper will be at camp. Please include any
over the counter medications that you will be sending along.
This camper will not take any daily medications while attending camp. This camper will take the following daily medication(s) while at camp: Name of Medication
Route of Administration
When it is given
Special Instructions
□ As Needed/Emergency* □ Other: ____________ □ As Needed/Emergency* □ Other: ____________ □ As Needed/Emergency* □ Other: ____________ *If your child has permission, knowledge, and skills to self-administer as needed/emergency medication please initial here ___ and indicate
it above. According to Maine State Law, be sure that your child’s physician also authorizes self-administration on FORM 2.
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. Cross out those the camper should not be given. If your child takes any other over the counter medication not listed, please send it along clearly
labeled with name and cabin and list it in the above table.
Acetaminophen (Tylenol)
Dextromethorphan cough syrup (Robitussin DM) Diphenhydramine antihistamine/allergy medicine (Benadryl) CAMPER HEALTH HISTORY FORM 1
Camper Name _________________________________________ Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Birth Date _____/_____/_______ Month Day Year General Health History: Check “Yes” or “No” for each statement. Explain “Yes” answers below.
Has/does the camper:
□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? Had asthma/wheezing/shortness of breath? □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? 10. Wear glasses, contacts, or protective eyewear? □Yes □No 20. Traveled outside the country in the past 9 months? 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.
Country: ________________________ Dates: _____/_____/_____ to _____/_____/_____ Country: ________________________ Dates: _____/_____/_____ to _____/_____/_____ Country: ________________________ Dates: _____/_____/_____ to _____/_____/_____
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? Ever been treated for emotional or behavioral difficulties or an eating disorder? During the past 12 months, seen a professional to address mental/emotional health concerns? 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) Please explain “Yes” answers in the space below, noting the number of the questions. The camp may contact you for additional information.
Health Care Providers:
Name of camper’s primary doctor(s): _________________________________________________ Phone: (______) _______________________________
Name of your 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
important or that may affect the camper’s ability to fully participate in the camp program. Attach additional information if needed.
INCLUDE A COPY OF YOUR INSURANCE CARD IF APPROPRIATE. PLEASE COPY BOTH SIDES OF THE CARD SO INFORMATION IS READABLE
Copyright 2008 by American Camping Association, Inc. Rev. 1/2007 LEE/EAW

Source: http://www.kieve.org/pdf/KWPrepare/k-w_camper_health_history_form_1.pdf

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