Microsoft word - iaumc health form - 2009.doc

Camper Health History & Authorization
This form is MANDATORY and must be completed by the legal guardian of any minor participant, as well
as all adult participants, attending camping events. This form is REQUIRED at the time of camper check-in
and the “Camp Authorization” and “Public Relations Release” (back page) MUST be signed.
Okoboji ● Pictured Rocks ● Wesley Woods

Name of Participant:_________________________________ Birth Date:________
Home address:__________________________________________________________________________________ (Street address) (City) (State) (Zip) Participant Social Security Number:_________________________________ Custodial parent/guardian:_______________________________________________________________________
Home address:__________________________________________________________________________________
(if different) (Street address) (City) (State) (Zip)
Home phone:_(____)__________ Work Phone: _(____)__________ Cell or other phone: _(____)__________ Other custodial parent/guardian:__________________________________________________________________
Home address:__________________________________________________________________________________
(if different) (Street address) (City) (State) (Zip)
Home phone:_(____)__________ Work Phone: _(____)__________ Cell or other phone: _(____)__________ If not available in an emergency, please contact:_____________________________________________________
Relationship:___________________________________________________ Phone: Address:_______________________________________________________________________________________
(Street address) (City) (State) (Zip)
INSURANCE INFORMATION – Please attach a copy of the front and back of health insurance card
Is the participant covered by family medical/hospital insurance? … Yes … No If so, indicate carrier or plan name:_______________________________________ Date of birth of policy holder:______________ Social Security # of policy holder:__________________________
Diet, Nutrition:
… This camper eats a regular vegetarian diet … This camper has special food needs (please describe below)
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Restrictions:
… I have reviewed the program/activities of the camp and feel that the camper can participate without restrictions … I have reviewed the program/activities of the camp and feel that the camper can participate with the following restrictions (please describe below) ___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Allergies:
… No known allergies … The camper is allergic to: … The environment (insects, hay fever, etc.) (please describe below what the camper is allergic to and the reaction seen) ___________________________________________________________________________________________
___________________________________________________________________________________________
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MEDICATIONS BEING TAKEN - "Medication" is any substance a person takes to maintain and/or improve their
health. This includes vitamins & natural remedies. All medications are collected, stored, and distributed by camp health
care personnel. Please list ALL medications (including over-the-counter or non-prescription drugs) taken routinely.
Bring only enough medications to last the entire time at camp. Keep it in the original packaging/bottle that
identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency
of administration.
… This camper will not take any daily medications while attending camp … This camper will take the following daily medication(s) while at camp: Med #1__________________________ Dosage_________ Specific times taken______________________ Reason for taking____________________________________________________________________________ Med #2__________________________ Dosage_________ Specific times taken______________________ Reason for taking____________________________________________________________________________ Med #3__________________________ Dosage_________ Specific times taken______________________ Reason for taking____________________________________________________________________________ Med #4__________________________ Dosage_________ Specific times taken______________________ Reason for taking____________________________________________________________________________ Med #5__________________________ Dosage_________ Specific times taken______________________ Reason for taking____________________________________________________________________________ … Camp staff has permission to administer over-the-counter medications as necessary.
The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Cross out those the camper should not be given.
Diphenhydramine antihistamine/allergy medicine Dextromethorphan cough syrup (Robitussin DM) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol)
Pill Count:

Med #1__________________________ In__________ Med #2__________________________ In__________ Med #3__________________________ In__________ Camper Check-in Camper
Check-out

GENERAL QUESTIONS – please explain “YES” answers below:
Has/does the participant:
Passed out/had chest pain during exercise? Had mononucleosis ("mono") during the past 12 months? If female, have problems with periods/menstruation? Have problems with falling asleep/sleepwalking? Had asthma/wheezing/shortness of breath? Have problems with diarrhea/constipation? Wear glasses, contacts, or protective eyewear? 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
countries visited and dates of travel.
_______________________________________________________________________________________________
_______________________________________________________________________________________________ _______________________________________________________________________________________________
Mental, Emotional and Social Health – check “YES” or “No” for each statement:
Has the camper:
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, others)
Please explain “Yes” answers in the space below, noting the number of the questions. The camp may contact you for additional information.
_______________________________________________________________________________________________
_______________________________________________________________________________________________ _______________________________________________________________________________________________
Which of the following has the participant had?

Immunization History:
Are the participants immunizations/vaccinations up to date? … Yes Name of Physician:________________________________________ Address:_______________________________________________________________________________________ Name of Dentist/Orthodontist:________________________________ Address:_______________________________________________________________________________________ DATE OF LAST HEALTH EXAM: ________________________________________
YOU WILL BE CONTACTED IF:
Your child is exposed to a communicable disease Outside medical attention is necessary (e.g., if we transport your child to a hospital/Dr. Office) • Your child is having discipline problems that jeopardize the safety of others 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.
_______________________________________________________________________________________________
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CAMP AUTHORIZATION
The undersigned person represents that he/she is the custodial parent/legal guardian of the above identified
participant. The Camper has my/our permission to attend the camping session from __________ to _________ (dates)
at Camp ________________ (Site Name). This permission is given by me/us with full knowledge of the conditions and
activities contemplated during each session (see conference camping catalog and/or site brochure for details). The
participant has no physical or mental disabilities that would impair their participation except as noted above. I/We
acknowledge, agree to, reconfirm and incorporate herein by reference the Release of Liability signed by me/us which
is attached hereto. I also understand that the information provided on this form will be kept confidential and shared
only as necessary to provide care for the participant.
I understand that camp insurance is a supplemental policy only. It will pay whatever my own insurance doesn’t cover
(deductible or over) up to the limit of the policy. If medical (sickness, injury) care is needed, billings will be sent to the
parent/guardian who will be responsible for direct payments to physician, hospital, clinic, etc…
The participant is currently taking only medications listed above. The camper has no allergies known to me/us except
as noted on this form. The health information/history is correct as far as I/we know. In the event of illness or injury, I/we
authorize the camp, physician and/or hospital to undertake such treatment of and perform such services (including
surgical) for the participant as are reasonably indicated by the circumstances.
Signature of LEGAL Parent/Guardian or Adult_______________________________ Date:_________________
Signature of 2nd LEGAL Parent/Guardian___________________________________
Date:_________________

My child will be riding home with____________________________________________
Phone#:______________
PUBLIC RELATIONS RELEASE
United Methodist Camp personnel may at their discretion, elect to include photographs of persons and events at United Methodist Camps in printed materials, news releases, film presentations, authorized camp or conference websites and the like for the purpose of advancing the mission of the United Methodist Camp program. I hereby give permission for photo or visual image of the above named individual to be used for such purposes, without compensation or prior approval rights, at any time with the understanding that said individual will not be identified by name, without permission. ____________________________________ _________ Recent exposure to communicable disease, Illness, Injury? Consent sections filled out, signed and complete? Meds. Checked in, pill counts documented? Staff Initials_____________________________ Date_________________

Source: http://www.wesleywoodsiowa.org/downloads/healthform.pdf