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Huizenga.nova.edu

Dates will attend camp: from ______________to_____________ Camper Name: _____________________________________________________________ Developed and reviewed by: American Camp Association, Male Female Birth Date ____________ Age on arrival at camp: ________ American Academy of Pediatrics Council on School Health, & To Parent(s)/Guardian(s): Please follow the instructions below. Attach additional information if needed.
Mail this form to the address below by _______ (date)
Complete pages 1, 2 and 3 of this form (FORM 1) and make a copy.
Send the original, signed FORM 1 to camp by the requested date.
Camper Home Address: ______________________________________________________________________________________________________ Parent/guardian with legal custody to be contacted in case of illness or injury: Name: ____________________________ to Camper: ________________Preferred Phones: (______) ________________(______)_________________ Home Address: _____________________________________________________________________________________________________________ (If different from above) Street Address Second parent/guardian or other emergency contact: Name: ____________________________ to Camper: ________________Preferred Phones: (______) ________________(______)_________________ Additional contact in event parent(s)/guardian(s) can not be reached: Name(s): __________________________ to Camper: ________________ Preferred Phones: (______) ________________(______)_________________ 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.)
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.)
Medical Insurance Information:
This camper is covered by family medical/hospital insurance Yes No Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable.
Insurance Company______________________________ Policy Number___________________________ Subscriber_____________________________________ Insurance Company Phone Number (______) ___________________ Parent/Guardian Authorization for Health Care:
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in
all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp 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 the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on
this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp 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.

Parent/Guardian __________________________________________________________________Date: 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. Page 1/4
Camper Name: ________________________________________________ Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Immunization History: Provide the month and year for each immunization. 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.
(chicken pox) Date: Meningococcal meningitis
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.

Parent/Guardian: ______________________________________________________________Date: 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
instructions 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.
Lunch Dinner Bedtime Other time:_____________ Lunch Dinner Bedtime Other time:_____________ Lunch Dinner Bedtime Other time:_____________ 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.
Diphenhydramine antihistamine/allergy medicine (Benadryl) Dextromethorphan cough syrup (Robitussin DM) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Copyright 2008 by American Camping Association, Inc. Camper Name: ________________________________________________ Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses General Health Histor
y: Check
"Yes" or "
No" fo
r each st atement. Exp
lain “Ye
s” answers below.
1. Ever been hospitalized? …………………………. Yes No 2. Ever had surgery? . …………. Yes No 12. Passed out/had chest pain during exercise? ….……………. Yes No 3. Have recurrent/chronic illnesses? .……….… Yes No 13. Had mononucleosis ("mono") during the past 12 months?. Yes No 4. Had a recent infectious disease? . …………. Yes No 14. If female, have problems with periods/menstruation?.……. 5. Had a recent injury? . …………. Yes No 15. Have problems with falling asleep/sleepwalking? . 6. Had asthma/wheezing/shortness of breath?. 16. Ever had back/joint problems?…….……….……………. Yes No 7. Have diabetes? . …………. Yes No 17. Have a history of bedwetting?………………….……………. Yes No 18. Have problems with diarrhea/constipation?………………. 9. Had headaches? …………………………………. Yes No 19. Have any skin problems?……………………. Yes No 10. Wear glasses, contacts, or protective eyewear? 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 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)? ………………………. 2. Ever been treated for emotional or behavioral difficulties or an eating disorder?……. 3. During the past 12 months, seen a professional to address mental/emotional health concerns?……….…………………………………. Yes No 4. Had a significant life event that continues to affect the camper’s life?. Yes No
(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 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.
Parents/Guardians: STOP here. The rest of this is form is completed when the camper arrives at camp. Keep a copy for your records.
Copyright 2008 by American Camping Association, Inc. Camper Name: ________________________________________________ Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Individual Health Record (For Camp Use Only)
Initial Screening
Date/Time: _________
Initials: ____________
Screening has been conducted according to camp protocol and significant findings noted as follows:
A. Any signs/symptoms of illness or injury upon arrival?. No Yes as noted below B. History of exposure to communicable disease?. No Yes as noted below C. Additions or corrections to information on this health history?. No Yes as noted below D. Medication given to health-care staff?. E. Any signs/symptoms of head lice?. No Yes as noted below Provider notes: (date/time/initial all entries) _____________________________________________________________________________
____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Exit Note: Check one of the following:
Left camp this day with no reported illness or injury symptoms. Left camp this day with the following problem/concern: ________________________________________________________________________________________________________________ This person was told about the problem and instructed about follow-up as noted above: __________________________________________ Date/Time: ___________ Initials: __________ Copyright 2008 by American Camping Association, Inc.

Source: http://www.huizenga.nova.edu/ExecEd/ESCAPE/documents/2014_Camper_Health_History_Form.pdf

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