Microsoft word - health form for camper.doc

New England Music Camp
Health History and Examination Form
8 Goldenrod Lane
The information on this form is not part of the camper acceptance Sidney, ME 04330
process, but it is gathered to assist in identifying appropriate care. This form, except for the "Health Recommendations of Licensed Healthcare Provider," is to be completed by the parents/guardians and camper. Please mail it to NEMC by May 30th.
Camper's Name _________________________________________________ Home address __________________________________________________ Birth date ________________ Age at Camp _____ _________________________________________________ guardian _______________________________________________________ emergency contact ______________________________________________ Home address ___________________________________________________ Home address ________________________________________________ ____________________________________________________ ________________________________________________ Business Address ________________________________________________ Business Address _______________________________________________ ______________________________________________________ ______________________________________________________ Business phone ______________________________ Business phone ________________________________ Cell phone _________________________________ Cell phone ____________________________________ If not available in an emergency, notify:

Name ________________________________________________ Relationship___________________________ Phone Number __________________________
Street, City, State, Zip code _______________________________________________________________________________________________________________
Please note that the following boxes must be completed for attendance at camp. Attach photocopies of medical/hospital insurance coverage and prescription
plan, if separate. FRONT and BACK of cards.
Insurance information
Is the participant covered by family medical/hospital insurance?  Yes
If so, indicate the name of the carrier or plan name ___________________________________________________________ Group number _______________________
Carrier address (street, city, state, zip code) _____________________________________________________________________________________________________
Name of insured _______________________________________________________ Relationship to participant______________________________________
Social Security Number of the policy holder or insurance I.D. number __________________________________
Does the above insurance cover prescription medications?  yes  no
If no, how do you normally pay for these medications?
 prescription plan name _______________________________ Person insured ____________________________________ ID/policy number _________________
 out of pocket
Permission to provide necessary treatment or emergency care:
I hereby give permission to the medical personnel selected by the camp director to order x-rays, routine tests or treatment; to release any records necessary for insurance
purposes; and to provide or arrange related transportation for me or my child. In the event that I cannot be reached in an emergency, I hereby give permission to the
physician selected by the camp director to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied
for trips outside of camp.
Signature of parent/
Guardian _________________________________________________ witness _______________________________________________ Date ____________________
I also understand and agree to abide by the restrictions placed on my camp activities. Signature of minor camper _________________________________________ Date ____________________ If for religious reasons, you cannot sign this, contact the camp for a legal waiver that must be signed for attendance.
Health History
The following information must be filled in by the parent/guardian/camper. It will give camp health care personnel the background to provide appropriate care. Keep a copy of the completed form for your records and no tify the camp health personnel of any changes when the participant arrives at camp. Give complete information so the camp can be aware of your needs.
Allergies (list all known)
_____________________________________________________________________ _____________________________________________________________________ __________________________________________________________________ _________________________ ___________________________________________________________________________________________________ Other allergies (list- include bee stings, hay fever, animal dander, etc) _________________________________ __________________________________________________________________ _________________________________ __________________________________________________________________
Medications being taken:
Please list all medications (including over-the-counter or nor-prescription drugs) taken routinely. Bring enough medication to last the entire time at camp. Keep it in the original container that identifies the name of the medication, dosage, frequency of administration and prescribing physician. Some generic over-the-counter medications are provided at camp. You may also send preferred over-the-counter medications.  This person takes no medications on a routine basis.  This person takes medications as follows: Medication #1 __________________________________________ Dosage __________  daily (please note times) _________________ Reason for taking _____________________________________________________________________________________________ Medication #2 __________________________________________ Dosage __________  daily (please note times) _________________ Reason for taking ___________________________ Pl ____________________________________________________________ Medication #3 __________________________________________ Dosage __________  daily (please note times) _________________ Reason for taking ____________________________________________________________________________________________ Medication #4 __________________________________________ Dosage __________  daily (please note times) _________________ Reason for taking ____________________________________________________________________________________________ Medication #5 __________________________________________ Dosage __________  daily (please note times) _________________ Reason for taking ____________________________________________________________________________________________ Identify and medications taken during the school year that the participant does/may not take in the summer ________________________________ ______________________________________________________________________________________________________________________ Please attach pages to submit additional information. Approved by _____________________________________________________________ Please check the over-the-counter medications you want your child to receive to relieve pain or other
discomforts.
General History: Check “True” or “False” for each statement

This camper has had chicken pox or has received the varicella immunization………………………….…………  This camper has NOT had mononucleosis (“mono”) during the past scho ol year…………………………………  This camper’s hearing is within normal ranges………………………… ………….………………………………  This camper’s sight is within normal ranges or uses corrective lens to remedy vision…………………….………  This camper typically sleeps without snoring, sleep talking or making di sruptive noises…………………………  This camper is prepared to fall asleep at night without supports such as reading or listening to music…….……  This camper is free of illness, injury or physical challenge that would aff ect program participation…………….  For girls: this camper knows about menstruation and/or has a normal menstrual history…………………………  This camper has history of head injury………….…….……………… …………………………………………  Explain:___________________________________________________ This camper has been in countries outside the United States in the past n ine months……………………………  If “True” list the countries and the length of time spent: Country :__________________________________________________Dates:_________________________________________________ Country :__________________________________________________ Dates:_________________________________________________ Camper’s Physician:_________________________________________ Office Phone:___________________________________________ Camper’s Orthodontist_______________________________________ Office Phone:___________________________________________
Mental, Emotional and Social Health: Check “Yes or “No”
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, bipolar disorder………………….……  3. This camper has an emotional health concern (Specifically:_____________________________________) ….………….….……  4. During the past academic year this camper has seen or is currently seeing a professional to address mental/emotional concerns…  If “yes” was the answer to any of the four statements above, attach a statement from your child’s professional (e.g., psychiatrist, physician) that addresses the a. Describes the concern and the camper’s management plan (including medications) while at camp b. Describes the behaviors that will indicate to our staff that your camper needs professional referral; and c. Provides a recommendation from this professional supporting your child’s participation in our camp program. 5. This camper has had a significant life event that continues to affect the camper’s life….…………….…………….…….…………  If “Yes”, please provide written information about the event – death of a loved one, family change, adoption, new sibling, survived a disaster – its impact upon your child’s life, and care tips for your child’s cabin counselors. Chronic Health Concerns: Check those that pertain to this camper and describe how you handle this at home.
 This camper has no chronic health concerns and is capable of full participation in the cam program.  This camper has the following chronic health concern(s):  Menstrual Cramps  Frequent Ear Infections Information about items above (attached if needed)____________________________________________________________________________ Provide any additional information about the participant’s behavior and physical, emotional, or mental health about which the camp should be aware ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Activity and dietary restrictions: __________________________________________________________________________________________________ Name of additional health service providers currently giving care_____________________________ phone:_____________________________________ Service provided:_____________________________________________________________________________________________________

Parent/Guardian Authorization: The health history is correct and complete as far as I know, and the person herein described has permission to engage in all camp
activities except as noted: Signed:__________________________________________________ Printed:___________________________________________Date:_____________________
Healthcare recommendations
by licensed healthcare provider for __________________________________________

Name of camper

This examination report page is to be completed and signed by the participant's primary care provider. It must be based on an
exam completed during the school year prior to the beginning of camp.

Date of exam _____________________
Blood pressure __________ Weight _________ In my opinion, the applicant  is  is not able to participate in an active camp program. The application is under the care of a physician for the following condition(s) _______________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Active treatment at the time of this report includes _____________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Recommendations and restrictions for camp program Treatment to be continued at camp _______________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Medications to be administered at camp (name, dosage, frequency) _____________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Any medically-prescribed meal plan or dietary restrictions ____________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Known allergies _____________________________________________________________________________________________ __________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Description of any limitations or restrictions of camp activities ________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Additional information for the camp health care staff ________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Please include a copy of immunization record with this form
Signature of licensed healthcare provider ____________________________________________ Date _____________________ Printed Name _______________________________________________________ Phone ______________________________ Address ________________________________________________________________________________________________ Street address

Source: http://nemusiccamp.com/wp-content/uploads/2012/03/Health-form-for-camper-2012.pdf