**** Medical Information/ Emergency Contacts/ Insurance/ Consent ****

Transcription

1 Arrival Departure Certification Level: **** Medical Information/ Emergency Contacts/ Insurance/ Consent **** Camper s Name: Birthdate: Age: Parent/Legal Guardian/Adult Leader Name: Day Time Phone: Evening Phone: Medical Insurance Information: Medical Insurance: Policy Number: Primary Insured Name: Relation to Camper: Primary Insured Phone: Primary Care Physician: Phone #: Medical Information to be Provided: Insurance Card (Copy front and back and attach) Date of last Tetanus Shot: Immunization Card (Copy front and back and attach) Immunization Waiver By checking this box, immunization information will not be provided as part of the medical information provided on this registration form. (This decision may only be made by a parent, legal guardian, 18 yr. old youth, or adult staff member) Height: Weight: Baseline Blood Pressure: / Medical History: Please if you presently have, or ever have incurred any of the following: Poison Oak Fainting Diabetes Rheumatic Fever Heart Trouble Headaches Eye Problems Dizziness Back Problems Lung Disease Physical Disabilities Mental/Emotional Disorder Asthma Allergies Convulsions, Epilepsy Hay Fever Menstrual Problems ADD/ADHD Sleep Walking Hypertension Food Allergies Allergic to Insect Stings Irritable Bowel Syndrome High Blood Pressure Stomach Problems No conditions as noted above Please if you have had any of the following in the past year: Ear Infections Surgery Any type of Injury Sore Throats Nose Bleeds Pink eye Head Lice Athlete s Foot Any type of skin rash No conditions as noted above Camper is currently under a physician s care for a physical or mental condition. Please explain above noted conditions, current medical care or restriction of activity : 1

2 **** Medical Information/ Emergency Contacts/ Insurance/ Consent **** Medications: ALL MEDICATIONS MUST BE CHECKED IN TO THE HEALTH SUPERVISOR AS DIRECTED List Prescription medications that will be taken by camper while attending Camp. If there are any changes to this list prior to the beginning of Camp, such changes MUST be communicated to the Health Care Supervisor before arrival at Camp. All medication must be in original container with original pharmacy medication sticker including camper s name. *Note: Place a check under Morning, Noon, or Evening as appropriate for administering of each medication. Medication/Dosage Related Condition Morning Noon Evening Over-the-counter (OTC) medications may be maintained by the Health Care Supervisor for use as needed. Please circle (Y)es or (N)o next to each OTC medication listed below indicating if said camper may or may not receive medication. Ibuprofen/Motrin Y N Tylenol/Acetaminophen Y N Advil Y N Bendadryl/Diphenhydramine Y N Tums/antacid Y N Pepto Bismol Y N Midol Y N Kaopectate Y N Aleve Y N Note any additional OTC medications not allowed for named camper: Special Instructions: Medication/Drug Allergies: Food Allergies/Special Dietary Needs: Consent to Treat: The following authorization shall remain effective for the duration of Young Women s Camp I, (print name), the undersigned, as parent/legal guardian, or myself state the above noted medical and health information is true and correct so far as I know and hereby authorize the Camp Health Supervisor, Camp Director, qualified members of the Young Women s Camp Staff, or driver of a transporting vehicle to obtain first aid or other care as seems prudent to above named individual in the event of accident or illness. I understand I will be held responsible for any medications brought to camp by person herein described. I hereby give permission to administer prescribed medication as well as over the counter medication according to as is indicated above. I further authorize said persons to initiate any or all provisions for medical and/or surgical care for above named individual, including anesthesia, which may be deemed necessary or advisable by any licensed First Responder, Emergency Room Personnel, or Physician. I assume and shall be responsible for all medical costs and expenses in connection with the care and control of above named individual, except in so far as there is applicable insurance covering the same. In the event of an incident requiring medical attention I expect that every effort will be made to notify myself or the below named emergency contacts. Parent/Legal Guardian/18 yr. Old Staff: Emergency Contacts: Name: Phone #1: Phone #2: Name: Phone #1: Phone #2: 2

3 ********Young Women s Camp Activities******** Young Women s Camp may include various activities such as swimming, backpacking, hiking, remote camping distant from the main Camp facility, campfire building, and outdoor cooking all of which may be a portion of the certification process within the Young Women s Camp program. Special activities such as Archery and/or a Ropes Challenge Course may also be included. Special Activities Note: The following 2 activities require specific consent and/or health forms to be completed. Such forms will be provided as needed. 1. Archery 2. R.O.P.E. Program (generally offered to a specified age group) Water Front/Swimming Activities The outdoor program at Young Women s Camp provides for water activities in the form of swimming and/or boating such as the use of a canoe. A portion of the lake at is roped off as a designated swim area. Swimming is allowed only when a certified life guard is present and all Church and State regulations are met. Please check appropriate boxes below: Swimming ability: Non-swimmer Beginner Intermediate Advanced/lifeguard Above noted Individual has permission to fully participate in Waterfront activities, as is planned as part of the Young Women s Camp program. Above noted Individual has permission to partially participate in Waterfront activities, as is planned as part of the Young Women s Camp program, Noting the following restrictions; I, agree to abide by all Waterfront Safety (Print Campers Name) Rules and Guidelines as explained by Adult Camp Staff Leaders. I agree to promptly follow all instructions provided by the onsite Lifeguard and will ensure my conduct provides for the safety of all other swimmers. Camper Name: I have read the section above (Water Front Activities). I have checked the appropriate boxes, and described any restrictions as needed: 3

4 ********Young Women s Camp Activities******** Backpacking/ Hiking/Remote Camping/Outdoor Cooking: Please check one box below: Above noted Individual has permission to fully participate in activities noted in this section as a planned portion of the Young Women s Camp program. Above noted Individual has permission to partially participate in activities noted in this section as a planned portion of the Young Women s Camp program, noting the following restrictions; I am aware of the activities in this section.(backpacking/hiking/remote Camping/Outdoor Cooking) I have checked the appropriate box and described any restrictions as needed. Responsible Authorization I, (print name), the undersigned, as parent/legal guardian/18 yr. old camper/or myself hereby give permission for the above mentioned individual to attend the supervised Young Women s Camp program of the Church of Jesus Christ of Latter-day I further grant, individual herein described, permission to engage in Young Women s Camp activities described herein, EXCEPT as noted. I further understand that in the case of illness, accident, or for any unforeseen issues, I am responsible to provide for the pick-up and transport home of said individual as deemed prudent by the Camp Staff. I further understand that the Staff reserves the right to ask herein described individual to be sent home from Camp in the case of disciplinary issues and that I am responsible to provide for the pick-up and transport home of said individual. Furthermore, I release all Camp leaders, the Camp Health Care Supervisor, including assisting Camp Health Care Staff, from any consequences that occur due to undisclosed prescription or over the counter medications brought to Camp by said individual. =========================================================================== Required Leader Certification Cards as is Appropriate; CPR Card: First Aid Card: Life Guard Card: 4

5 24 Hour Medical Screening () ( Health screening shall be conducted under the supervision of the Camp Health Care Supervisor ) *Please circle (Y)es or (N)o for each of the following questions: 1. Any changes to Emergency/Contact information? (note changes on back) Y N 2. Any new allergies? (note changes on back) Y N 3. Any new restrictions? (note change on back) Y N 4. Any new medication? (note change on back) Y N 5. Any change to medication? (note change on back) Y N 6. Does individual have any rashes? Y N 7. Does individual have Athlete s Foot? Y N 8. Any open wounds or sores? Y N 9. In the past 48 hours, any exposure to Pink Eye? Y N 10. In the past 48 hours, any exposure to Head Lice? Y N 11. In the past 48 hours, any exposure to Strep Throat? Y N 12. Fever in the past 48 hours? Y N 13. Diarrhea or vomiting in the past 48 hours? Y N 14. Any other changes not mentioned? (please explain on back) Y N If you answered YES to any of the above, please explain: Note: Parent/Legal Guardian must evaluate named camper regarding above questions immediately prior to the 24 hour screening and sign below. Parent/Legal Guardian not required to attend screening. Parent/Legal Guardian/18 yr. old Camper/Staff: Name: Name: FOR CAMP HEALTH CARE SUPERVISOR USE ONLY 24 Hour Screening Evaluator Comments: 24 Hour Screening Evaluator Name: Name: Camp Health Care Supervisor Name: *Note: Information acquired from this screening is for strict use of the Camp Health Care Staff and does not imply that a Camper is not allowed to attend Camp. Any action taken is at the discretion of the Camp Health Care Supervisor. 5