Camp chen-a-wanda camper health history form

Camp Chen-A-Wanda Camper Health History Form Please complete pages 1-3 and 5 and have your child’s Name: __________________________________________________ physician complete and sign page 4. All forms
must be completed and submitted along with
Dates of Attendance ___________ to __________ copies of your child’s health insurance cards by
by June 1st for camp to give treatment.
[ ] Male [ ] Female Date of Birth __________ Age as of 6/27/10 _____ Camper Home Address: ________________________________________________________________________________ Parent/guardian with legal custody to be contacted in case of il ness or injury: Name: _______________________ Relationship to Camper: _________________ Email: ________________________ Home: ( ) ____________________ Cell: ( ) ____________________ Work: ( ) ____________________ Home Address: _______________________________________________________________________________________ (if different from above) Street Address Second Parent/Guardian or other emergency contact: Name: _______________________ Relationship to Camper: _________________ Email: ________________________ Home: ( ) ____________________ Cell: ( ) ____________________ Work: ( ) ____________________ Additional contact in event parent(s)/guardian(s) cannot be reached: Name: _______________________ Relationship to Camper: _________________ Email: ________________________ Home: ( ) ____________________ Cell: ( ) ____________________ Work: ( ) ____________________
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 al 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 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 wil 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 ____________ Health Care Providers:
Name of camper’s primary doctor(s):________________________________ Name of camper’s dentist(s):______________________________________ Name of camper’s orthodontist(s):__________________________________ Allergies: [ ] No known allergies
[ ] To Food (list): _________________________________________________ [ ] [ ] To medication (list): ____________________________________________ [ ] [ ] To environment (insect stings, hay fever, etc. list): ___________________ [ ] [ ] Other al ergies (list): ___________________________________________ [ ] Describe previous reactions: ____________________________________________________________________________
_____________________________________________________________________________________________________ Parents, please make sure your child is aware or his/her allergies as well as the severity and the course of action to be taken.
Restrictions: [ ] I have reviewed the program and activities of the camp and feel the camper can participate without restriction.
[ ] I have reviewed the program and activities of the camp and feel the camper can participate with the fol owing restrictions or adaptations. (Please describe) _________________________________________________________________________
______________________________________________________________________________________________________________
Diet, Nutrition: [ ] This camper eats a regular diet.
[ ] This camper eats a regular vegetarian diet. [ ] This camper has special food needs. (Please describe) _______________________________________
____________________________________________________________________________________________________ Camp Chen-A-Wanda Camper Health History Form
Name: ____________________________________________ Bunk: ___________ Date of Birth _____________________
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. Immunization
Month/Year Month/Year Month/Year Month/Year Tuberculosis (TB) test Date: _____________ [ ] Negative If your camper has not been ful y immunized, please sign the fol owing statement: I understand and accept the risks to my
child from being ful y immunized.
Parent/Guardian: ____________________________ Date: ____________ to Camper: __________________________
Medication:
[ ] This camper will not take any daily medications while attending camp. [ ] This camper will take daily medications while at camp. If yes, fil out the Medication Submission Form and submit with needed medications.

Camp Chen-A-Wanda Camper Health History Form
Name: ____________________________________________ Bunk: ___________ Date of Birth _____________________
Non-prescription medications: These wil be stocked in the camp Health Center and are used on an as needed basis to
manage il ness and injury. Please indicate which can and cannot be used for your child. Both Generic and brand name medications are used in the Health Center. The determination of need for these medications will primarily be made by our RN staff or the MD on cal and they wil be administered according to the directions on the package. General Health History: Please check “Yes” or “No” for each statement. Explain “Yes” answers below.
12. Passed out/had chest pain during exercise? 13. Had mononucleosis during the past year? 14. If female, have problems with periods/menstruation[ ] 15. Have problems with falling asleep/sleepwalking? 16. Had asthma/wheezing/shortness of breath? 18. Have problems with diarrhea/constipation? 10. Require meds. for motion sickness? [ ] 20. Wear glasses, contacts, protective eyewear? 21. Traveled outside the US within the past 9 months? [ ] Please explain “Yes” answers. Note the question’s number, and for travel outside of the US, 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? 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, other) Please explain “Yes” answers. Note the question’s number. The camp may contact you for additional information.
_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
Parents/Guardians: STOP here. Please submit final page of form to your child’s healthcare provider to be fil ed out and
signed. No child may be seen by the camp health staff without proper medical forms. Al forms must be submitted to the
camp office no later than June 15th. Before June 1st, please mail forms to 1 Ellis Ct. Woodcliff Lake, NJ 07677 or fax to
(201)391-2295. After June 1st, please mail forms to 355 Camp Rd. Thompson, PA 18465 or fax to (570)756-2086
Camp Chen-A-Wanda Camper Health History Form
Name: ____________________________________________ Bunk: ___________ Date of Birth _____________________
Medical Personnel: Please review pages 1-3 of this form and complete page 4. Attach additional information if needed.

Physical exam done today: [ ] Yes
Date: ______________ [ ] No Date of last physical: ____________________ A physical exam must be completed within the 24 months prior to the camp season.

Allergies: [ ] No known allergies
[ ] To Food (list): _________________________________________________ [ ] [ ] To medication (list): ____________________________________________ [ ] [ ] To environment (insect stings, hay fever, etc. list): ___________________ [ ] [ ] Other al ergies (list): ___________________________________________ [ ] Describe previous reactions: ____________________________________________________________________________
____________________________________________________________________________________________________ ____________________________________________________________________________________________________
Diet, Nutrition: [ ] Eats a regular diet. [ ] Has a medically prescribed meal plan or dietary restrictions: (describe below).
_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ ____________________________________________________________________________________________________
This camper is undergoing treatment at this time for the fol owing medical conditions: (describe below) [ ] None
_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
Medication [ ] No daily medications [ ] will take the following prescribed medication(s) while at camp
Reason for Taking
How Given
Frequency
_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
Other treatments/therapies to be continued at camp (describe below) [ ] None needed
_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Do you feel that the camper wil require limitations or restrictions to activity while at camp? [ ] No [ ] Yes (describe)
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

“I have reviewed the Camper Health History Form and have discussed the camp program with the camper’s
parent(s)/guardian(s). It is my opinion that the camper is physically and emotionally fit to participate in an active camp Name of licensed provider (please print) _______________________ Signature ______________ Title __________________ Office Address _________________________________________________________________________________________ Telephone: ( ) _________________________________ Date: ___________________________________________ Camp Chen-A-Wanda Camper Health History Form Name: ______________________________________________ ___ [ ] Male [ ] Female Date of Birth _____________ Camper Home Address: ________________________________________________________________________________ Parent/guardian with legal custody to be contacted in case of il ness or injury: Name: _______________________ Relationship to Camper: _________________ Email: ________________________ Home: ( ) ____________________ Cell: ( ) ____________________ Work: ( ) ____________________ Home Address: _______________________________________________________________________________________ (if different from above) Street Address _____________________________________________________________________________________________________
Medical Insurance Information:
This camper is covered by family medical/hospital insurance [ ] Yes [ ] No Camper’s Social Security # _____-____-_______ 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 ( ) ___________________ Policy Holder’s Social Security # _____-____-_______ Policy Holder’s Contact Number ( ) ______________________ Attach Copy of Front of Insurance Card HERE Attach Copy of Back of Insurance Card HERE In the event that your child needs medical attention outside of camp, you will be notified by a member of our staff.
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 al 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 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 wil 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 ____________ Allergies: [ ] No known allergies
[ ] To Food (list): _________________________________________________ [ ] [ ] To medication (list): ____________________________________________ [ ] [ ] To environment (insect stings, hay fever, etc. list): ___________________ [ ] [ ] Other al ergies (list): ___________________________________________ [ ] Describe previous reactions: ____________________________________________________________________________
_____________________________________________________________________________________________________
Indicate any major il nesses, injuries or surgeries that cause camper to be hospitalized as well as date of hospitalization.
Please also include any medical conditions we should be aware of in the event that the camper needs to go to the hospital.
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

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