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Microsoft word - 2010 health form

2010 Health Form Page 1 of 4
Camper Name
Please complete and RETURN TO CAMP BY MAY 1st for all sessions. PLEASE PRINT.
If enrolling after May 1st, please return ASAP.

Camper Name
: ___________________________________________ Session: ________________

:_____________________________ (For Camp Use) Age: _____________________ Birthday: __________________________ Gender: Male
*Information must be completed by Parent/Guardian of Minors for all parts of form. Please do not write “see prior year’s information” or “see other forms”.

Parent/Guardian: _________________________________________________________________________________
Home Phone: ________________________________ Home Address: ___________________________________ City/State/Zip: ________________________________ Father’s Cell: _______________________________ Mother’s Cell: _________________________________ Business: If parent/guardian is not available in an emergency, notify: 1) Name: ________________________________________ 2) Name: _____________________________________ Relationship: ____________________________________ Relationship: ________________________________ *AUTHORIZATION (REQUIRES SIGNATURE):
IMPORTANT – MUST BE COMPLETED FOR ATTENDENCE: The camper listed above has my permission to engage in all
Camp Lincoln/Camp Lake Hubert activities and programs whether those take place on or off camp property except as noted on this
form and under all terms of the enrollment agreement that I have already received. I agree that my camper is voluntarily
participating with the knowledge of the inherent and other risks (both known and unknown) in these activities and programs. My
camper and I accept full responsibility for any injury, damage, death or other loss resulting from these risks and/or resulting from
my camper’s own negligence or other misconduct.
AUTHORIZATION FOR TREATMENT: I hereby give permission to the camp to provide routine health care, administer
prescribed medications, and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of
any records necessary for insurance purposes. I give permission to the camp to arrange necessary related transportation for me/my
child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure
and administer treatment including hospitalization, injections, anesthesia or surgery, for the person named above. This completed form may be photocopied. This camp has permission to obtain copies of my child’s treatment and health record from any provider who treats my child. I understand that information about my child’s health will be shared on a “need to know” basis with camp staff. I will notify the camp in writing of any health related changes between the date of this form and my camper’s arrival at camp. This camp health form is complete to the best of my knowledge and contains no misrepresentations or omissions that might or
would affect my child’s experience at camp.
*Signature of Parent/Guardian: __________________________________________________ Date: ________________
2010 Health Form Page 2 of 4
*Immunization History:
Provide the month and year for each immunization or attach a copy of your child’s clinic/school immunization record. Starred ()
immunizations must be current.
If you camper has not been immunized, please explain why and/or attach supporting documentation. ______________________________ ______________________________________________________________________________________________________________ *Medication:
“Medication” is any substance a person takes to maintain and/or improve his or her health and includes vitamins and homeopathic remedies.
This camper will not take any daily medications while attending Camp Lincoln/Camp Lake Hubert. This camper will take the following medication(s) while attending Camp Lincoln/Camp Lake Hubert. Bring enough of each med to last the entire session. Campers takings meds for psychiatric reasons should be on the same medication at the same does for the three months prior to their arrival. Note: All medications must arrive in the original, appropriately labeled pharmacy containers (as described in the Parent Handbook).

Lunch Dose: _______ Evening Dose: ______ Bedtime Dose: ______ Lunch Dose: _______ Evening Dose: ______ Bedtime Dose: ______ The following generic medications are stocked in the camp health center and are used to manage illness and injury as directed by our
medical protocols. Cross out those your camper should NOT be given.
Parent/guardians are financially responsible for health care given by an out-of-camp provider for medication, illness, treatment,
pre-existing conditions, etc.
Please include a copy of an insurance card. Copy both sides so addresses and telephone numbers are readable.
Insurance Company: _____________________________________________________________________________________
Claims Address: _________________________________________________________________________________________
Policy number for your child: ______________________________________________________________________________
IMPORTANT: Please notify the camp if this camper is exposed to any communicable diseases prior to camp attendance.
2010 Health Form Page 3 of 4
** Asthma, Diabetes or
GENERAL HEALTH HISTORY: Check “Yes” or “No” for each statement. Explain “Yes” answers below.
Operations or serious injuries (list dates & condition below) Allergies to any medications (explain below) ** (Girls) if not, has she been told about it Any chronic recurring conditions (i.e. seizures, ear infections, etc.) Special Equipment (e.g. ear plugs, braces, retainers) Wear glasses, contacts, or protective eyewear Traveled outside the country in the past 9 months Any conditions or restrictions that effect participation in the program (explain below) Please explain “Yes” answers in the space below or on a separate sheet. For travel outside the country, please list name of countries visited and dates. HEALTH-CARE PROVIDERS:
Name of camper’s primary doctor(s): ______________________________________ Phone: ______________________ Name of dentist(s): ____________________________________________________ Phone: ______________________ Name of orthodontist(s) ________________________________________________ Phone: ______________________ MENTAL, EMOTIONAL AND SOCIAL HEALTH: Check “Yes” or “No” for each statement.
1. This camper has been diagnosed with Attention Deficit Disorder (ADD) or AD/HD .
2. This camper has a psychiatric diagnosis such as depression, OCD, panic/anxiety disorder, eating disorder . 3. This camper has an emotional health concern (specify__________________________________) 4. During the past academic year, this camper has seen or is currently seeing a professional to address If “yes,” was the answer to any of the four statements above, attach a statement from your camper’s professional (e.g., psychiatrist, physician) that addresses the following three things: (a) Describes the concern and the camper’s management plan (including medication) while in our program; (b) Describes the behaviors that will indicate to our staff the your camper’s needs professional referral; and (c) Provides recommendation for the camper’s participation in our program. 5. This camper has had a significant life event that continues to affect the camper’s life . If “yes,” please attach written information about the event – death of a loved one, family change, adoption, new sibling, survived a disaster—its impact upon your camper’s life, and care tips for the cabin staff. Keep in mind our staff are generally college students. 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 form is comple ted when the camper arrives at camp. Keep a copy for your records.
Camper Name
: ___________________________________________ Session: ____________________
2010 CAMPER HEALTH RECORD (For Camp Use Only) Page 4 of 4
SCREENING has been conducted according to camp protocol and significant findings noted. A. Any signs/symptoms of illness or injury upon arrival? B. History of exposure to communicable disease? . C. Additions or corrections to information on this health history? . D. Medication given to healthcare staff? . ____________________________________________________________________________________________________
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: _________________________________________ Initials: _______________________________________________________________________________________ This person was told about the problem and instructed about follow-up as noted above: ______________________________


T:\109cv1761\final order (jamiah).wpd

Case 1:09-cv-01761-AJB Document 27 Filed 05/17/10 Page 1 of 58 IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF GEORGIA ATLANTA DIVISION GRACIE MARIE JAMIAH, Plaintiff, CIVIL ACTION FILE NO. 1:09-CV-01761-AJB MICHAEL J. ASTRUE, Commissioner of Social Security Administration , Defendant. ORDER 1 AND MEMORANDUM OPINION Plaintiff, Gracie Ma

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