Microsoft word - mpe health and otc form camper.doc

Last Name:
First Name:
Name last ___________________________ first _____________________________ Medication Allergies (list)
Describe reaction & management of reaction Age ________________________________ Birthdate ________________________ ________________________________________ Parent/Guardian ______________________________________________________ ________________________________________ Home Phone ( ) __________________ Work Phone ( ) _______________ ________________________________________ Cell Phone ( ) ___________________ e-mail __________________________ ________________________________________ Home Address _______________________________________________________ Food Allergies (list)
Describe reaction & management of reaction City ____________________________ State ________ Zip Code _______________ ________________________________________ ________________________________________ Emergency Contact (other than parent):
________________________________________ Name last ___________________________ first ____________________________ ________________________________________ Day phone ( ) ____________________ Night phone ( ) ________________ Other Allergies (list)
Describe reaction & management of reaction ________________________________________ Insurance – Is the participant covered by family medical insurance? yes no
________________________________________ Insurance Carrier or Plan Name _________________________________________ ________________________________________ Group # ____________________________________________________________ ________________________________________ (Photocopy of front and back of health insurance card must be attached to this form.) Medications Will the camper be bringing any medications to camp? No Yes
Health History (please explain “yes” answers below.)
This person takes medications as follows: (include prescription and over-the-counter) 1. Had an recent injury, illness 13. Have an orthodontic Med #1 ____________________ Dosage _______ Times taken each day _________ Reason for taking ______________________________________________________ 2. Have a chronic or recurring 14. Have diabetes? Med #2 ____________________ Dosage _______ Times taken each day _________ 3. Ever been hospitalized? 16. Had mononucleosis Reason for taking ______________________________________________________ Med #3 ____________________ Dosage _______ Times taken each day _________ 5. Have frequent headaches? 17. Had problems with Reason for taking ______________________________________________________ 6. Ever had a head injury? diarrhea or constipation? Please attach additional pages for more medications. Both over-the-counter and 7. Ever been unconscious? 18. Sleepwalk? prescription meds to be administered at camp must be in the original pharmacy-labeled containers with the patient’s name, dosage, time of administration, and any special instructions clearly stated. Please, only one medication per container. 10. Have high blood pressure? 21. Emotional difficulties? For Females - has she menstruated?
Please explain any “yes” answers, noting the number of the questions. If yes, is her menstrual history normal? ________ If no, does she know about it? _____ ______________________________________________________________________
Other Special Considerations
______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Please attach additional pages if needed for further explanation. Non-Prescription Medication Permission
Immunization History
I hereby grant permission for the Mojave Primitive Encampment to dispense the following over-the- Please note – Immunization dates must be included on this form. Stating that immunizations are current or up-to-date is not adequate. This information is available from your doctor. Signature _______________________________________________ Date __________________ Camper’s height: ___________________________ Camper’s Weight: ______________________ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ (Please check all medications that MPE has permission to dispense to your daughter ______ ______ ______ ______ ______ ______ and note any special instructions.) ______ ______ ______ ______ ______ ______ Acetaminophen – generic Tylenol (minor aches and pain) ______________________________ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ Arnica (ointment for muscle soreness/bruising) ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ Baking Soda – Paste (bites and stings) ______ ______ ______ ______ ______ ______ Benadryl – cream / tablets (stings, bites, colds, allergies) ______________________________ ______ ______ ______ ______ ______ ______ Betadine (ointment or solution for cleaning abrasions) ______ ______ ______ ______ ______ ______ Calamine Lotion (itching from insect bites) Cepacol/Halls/generic – throat lozenges (sore throat) Parent / Guardian Notification Policy
Dacriose/generic eye wash or sterile saline On rare occasions, due to health or safety concerns, campers are unable to complete the full camp program. If any of the following situations occur, a parent/guardian will be contacted and the Gas relief capsules (for upset stomach / gas) appropriate measures will be decided upon. Honey (sterile antibacterial - for cut / wound care) Hydrocortisone Cream – Cortaid and/or Caladryl (itching) ______________________________ A camper who is excessively sick and/or is in the first aid tent for over 12 Ibuprofen – generic Advil (minor aches, pain, cramps) A camper who makes four or more visits to the first aid tent because of an A camper who is taken to the emergency room A camper who is a danger to herself and/or to others Neosporin antibiotic ointment (minor scrapes, cuts) Authorization & Permission to Provide Necessary Treatment or Emergency Care:
The undersigned do hereby authorize the officers, leaders or agents of Girl Scouts of Greater Los Angeles, to consent to any x-ray examination, anesthetic, medical or surgical treatment and Sore Throat spray – generic brands (sore throats) hospital care to be rendered to said minor under the general or special supervision and upon the advice of a physician or surgeon licensed under the provisions of the Medical Practice Act, or to consent to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital Vaseline - night time use only (nosebleeds) care rendered to said minor by a dentist licensed under the provisions of the Dental Practice Act. It is further understood that permission is hereby granted to the officers, leaders or agents of Girl Scouts of Greater Los Angeles to obtain and administer such medical aid or assistance as might, in their judgment, be required for the immediate care of your daughter. In the event of such help, Girl Scouts of Greater Los Angeles, its officers, leaders and agents will not be held liable for any first ______________________________________________________________________ aid treatment or hospital care rendered drugs, medicine or surgical procedures performed pursuant to this consent. This consent supersedes all prior authorization. ______________________________________________________________________ ______________________________________________________________________ Signature of Parent / Guardian ____________________________ Date ___________

Source: http://www.mpehome.org/docs/2011/MOJAVE%20HEALTH%20FORM%20CAMPER.pdf