Microsoft word - meds auth form-2012.doc

Attending: 1st Session 2nd Session (Circle one) Camper Name: ____________________________________________________ Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health & Please Return by May 15, 2013 to:
Parents: Please fill out pages 1 and 3, sign and give to your child's doctor to complete pages 2 and 4.
Fax: 845-262-1091/email: michele@kencamp.com Parent and doctor signatures are required.
After May 15th please mail to:
Please send (with appropriate paperwork) to our office when complete.
PLEASE KEEP A COPY FOR YOUR RECORDS.
Fax: 860-927-4487/email: michele@kencamp.com Camper Home Address: ______________________________________________________________________________________ Parent/Guardian with legal custody to be contacted in case of illness or injury:
Name: _________________________ Relationship to Camper: ____________________ Preferred Phone: ________________
Email: ________________________________
Home Address: _____________________________________________________________________________________________
(If different from above)
Second parent/guardian or other emergency contact:
Name: _________________________ Relationship to Camper: ____________________ Preferred Phone: ________________
Email: ________________________________
Additional contact in event parent(s)/guardian(s) can not be reached:
Name: _________________________ Relationship to Camper: ____________________ Preferred Phone: ________________
Allergies:
This camper is allergic to Circle all that apply below
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 vegetarian diet This camper has special dietary 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:
If yes, please provide copy of Insurance Card (Front and Back), thank you.
Parent/Guardian Authorization for Health Center
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 hospitilize, 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.
Signature of Custodial
Parent/Guardian
_________________________________________ Date: _______________ Relationship to Camper: ____________
If for religious reasons, you can not sign this, contact the camp for a legal waiver which must be signed for attendance. Pg 1/5 PARENT / GUARDIAN: PLEASE FILL OUT AND SIGN THIS PAGE.
Camper Name: ___________________________________________ Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health & 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.
Immunization
Most Recent Dose
Month/Year
Month/Year
Month/Year
Month/Year
Month/Year
Month/Year
Diptheria, tetanus, pertussis* (DTaP) or (TdaP)Tetanus booster * (dT) or (TdaP) Mumps, measles, rubella* (MMR)Polio* (IPV)Haemophilus influenzae type B (HIB)Pneumococcal (PCV) Hepatitis AVaricella Had Chicken Pox (chicken pox) Date:Meningococcal meningitis (MCV4) 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: _______________ Medication: ________ This camper will not take any daily medications/vitamins/supplements while attending camp.
________ This camper will take the following daily medications/vitamins/supplements while at camp: "Medication is any substance a person takes to maintain and/or improve their health." This includes vitamins & natural
remedies. All medications/supplements/vitamins must be ordered via CampMeds.
The following non- prescription medications are commonly stocked in the camp Health Center and are used on
an as needed basis to manage illness and injury. Medical Personnel: Cross out those items 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 Camp Association, Inc. Page 2/5 Rev. 1/2007 LEE/EAW CHILD'S DOCTOR TO FILL IN IMMUNIZATION HISTORY OR ATTACH COPY OF RECORDS.
If applicable, CHILD'S DOCTOR TO COMPLETE BOTTOM PORTION FOR ANY MEDICATION TAKEN AT CAMP AS WELL AS THE STATE OF CT MEDICAL AUTHORIZATION FORM (last page of this document)
Camper Name: _____________________________________________________ Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health & General Health History: Check "Yes" or "No" for each statement. Explain "Yes" answers below.
1. Ever been hospitalized? …………….….
11. Had fainting or dizziness? …………….
2. Ever had surgery? ………………………… 12. Passed out/had chest pain during exercise? …….….
3. Have recurrent/chronic illnesses?.
13. Had mononucleosis ("mono") during the past 12 months? 4. Had a recent infectious disease? ……….
14. If female, have problems with periods/menstruation? … 5. Had a recent injury? ……………………… 15. Have problems with falling asleep/sleepwalking? …….
6. Had asthma/wheezing/shortness of breath? 16. Ever had back/joint problems? ………………………… 7. Have diabetes? …………………………… 17. Have a history of bedwetting? ………………………….
8. Had seizures? …………………………….
18. Have problems with diarrhea/constipation? …………… 9. Had headaches? ………………………….
19. Have any skin problems? ……………………………….
10. Wear glasses, contacts or protective eyewear? 20. Traveled outside the country in the past 9 months? ….
Please explain "Yes" answers in the space below, noting the number of the questions. For travel outside the country, please name the 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 (ADHD)? …………………….
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, 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): ________________________________________________ Name of dentist(s):_______________________________________________________________ Name of orthodontist(s): __________________________________________________________ What have we forgotton 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.
Copyright 2008 by American Camp Association, Inc.
PARENT / GUARDIAN: PLEASE COMPLETE THIS PAGE Camper Health History Form 2013
Camper Name: _______________________________________________
Child's Doctor: Please fill out all information on this page. A copy of the Physical Exam Records can be attached.
Doctor's signature is required below.
The following non- prescription medications are commonly Doctor's Office: Please attached physical exam records or fill in below:
stocked in camp Health Centers and are used on an as needed basis to manage illness and injury.
Physical Exam done Today:
Medical Personnel: Cross out those items the camper should NOT be given. (If "No", date of last physical: ____________________) ACA Accreditation standards specify physical exam within last 12 months.
Weight _________ lbs Height: _____________ Blood Pressure ______/______ Chlorpheneramine maleateGuaifenesin cough syrup (Robitussin) Dextromethorphan cough syrup (Robitussin DM) Allergies:
Diphenhydramine antihistamine/allergy medicine (Benadryl) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Describe Previous Reactions:
Diet, Nutrition:
Has a medically prescribed meal plan or dietary restrictions
(describe below):
The camper is undergoing treatment at this time for the following conditions: (describe below):
Medication:
Will take the following medications / vitamins while at camp
(name, dose, frequency-describe below)
Other treatments/therapies to be continued at camp: (describe below)
Do you feel that the camper will require limitations or restrictions to activity while at camp?
If you answered "Yes" to the question above, what do you recommend? (describe below-attach additonal information if needed)
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 program (except as noted above).
Name of licensed provider (please print): _____________________________ Signature: _____________________ Title: ______________
Office Address: ____________________________________________________________________________________________________ Telephone: ______________________________ Copyright 2008 by American Camp Association, Inc. Page 4 of 5 CHILD'S DOCTOR TO COMPLETE AND SIGN THIS PAGE.
PLEASE FILL OUT ONE FORM FOR EACH MEDICATION and send to camp office
2013 State of CT – Medical Authorization Form
To be completed by MD / APRN / or PA and PARENTS THIS FORM IS TO BE FILLED OUT FOR ANY AND ALL MEDICATIONS AND SUPPLEMENTS-
PRESCRIPTION/OVER THE COUNTER DRUGS; HERBAL SUPPLEMENTS; VITAMINS; TOPICAL CREAMS ETC.
Authorized Prescriber’s Order (Physician, Advanced Practice Registered Nurse, Physician Assistant):
Name of Child ____________________ Date of Birth ___/___/___ Today’s Date ___/___/___ Medication (ONE ONLY) ____________________________________ Controlled Drug? YES NO
Dosage (MG ONLY) _________ Method (ORAL/TOPICAL etc) _______________ Daily or PRN (Circle)
Time of Administration (AM/PM/BID/Specific Hour/ PRN etc)_____________________________
Reason for Medication (Asthma/Allergy/ADHD etc)____________________________________________
Additional Instructions for Medication Administration __________________________________________ Medication Administration: Start Date _____/_____/_____ Stop Date _____/_____/_____ Relevant Side Effects of Medication _____________________________________________________ Permission to carry and to self administer a Rescue Inhaler or EpiPen? YES NO
Known Food or Drug: Allergies? YES NO Reactions to? YES NO Interactions with? YES NO
If “yes” to any of the above, please explain ________________________________________________ Prescriber’s Name___________________________________ Phone Number (____) _____________ Prescriber’s Address _________________________________________________________________ X____________________________________________ X ________________________
Prescriber’s/Doctor’s Signature Date
Parent/Guardian Authorization:
I request that medication be administered to my child as described and directed above. Print Name of Parent/Guardian Authorizing Administration of Medication: First Name _________________________ Last Name ______________________________ Relationship to Child: Mother Father Guardian/Other explain: ___________________________ Permission to carry and to self administer a Rescue Inhaler? YES NO
Permission to carry and to self administer an EpiPen? YES NO
X________________________________________________________ X______________________ Signature of Parent/Guardian Date
Name of Camp Personnel Receiving Written Authorization and Medication _________________________
Signature and Title/Position ___________________________________________________

Source: https://www.kmkwcamp.com/_/_c_forms/pdfs/2013CamperHealthHistory.pdf