Health History Form- Residential Camps

Office: 1-888-370-7287 - E-mail: [email protected]

HEALTH HISTORY FORM- RESIDENTIAL CAMPS

Camper Name Camper Age

Family Doctor: Doctor’s Phone: Health Insurance Policy Number: Company:

Section 1: ALLERGIES:

List allergies below

Allergy Type: Allergen: Reaction: Management:

Section 2: HEALTH QUESTIONS

Circle Yes or No, and explain additional information below

Does the participant wear glasses or contact Yes Have frequent Yes No Ever had surgery? Yes No lenses? No headaches?

Ever had a head injury? Yes Yes No Has asthma? Ever had ear infections? Yes No No

Ever had emotional difficulties for Treated/diagnosed with Ever had back problems? Yes Yes No which professional help was sought? attention deficit/attention Yes No No hyperactivity disorder Had mononucleosis in the Have Diabetes Yes Had seizures last 12 months? Yes No Yes No No Does the camper have a server and chronic developmental disability? (mental retardation, cerebral palsy, epilepsy, autism or neurological impairment) Yes No. If yes please call the office prior to registration to discuss in more detail.

Additional Information/Is there any other medical issue that we should be aware of?

Page 1 of 3 Section 3: MEDIACTION – DAY CAMPS

For day camps, RBNYA do not allow campers to bring on camp prescription or over the counter medication and do not provide a secure area to store medication. Any camper that requires medication must have a parent or guardian at camp to store and administer the medication.

At the current time of registration, will the camper be required to take any medication while attending camp?

( ) Yes ( ) No

If yes, please confirm that a parent or guardian will be at camp to administer the medication?

( ) Yes

Does your child have a severe food allergy that requires an epipen or benadtyl ( ) Yes ( ) No

Section 4: OVERNIGHT CAMPS ONLY

(a) MEDICAL QUESTIONS

Have problems with Have problems with sleep Yes falling asleep? Yes No Yes No History of bedwetting walking No

If applicable, has this camper started menstruation? ( ) Yes ( ) No

(b) DIET AND NUTRITION

This camper eats a regular diet ( ) Yes ( ) No

IMPORTANT NOTE: For campers with special dietary needs please call the office before registering to ensure that the host facility can accommodate the request

This camper eats a regular vegetarian diet ( ) Yes ( ) No

This camper is lactose intolerant ( ) Yes ( ) No

This camper is gluten intolerant ( ) Yes ( ) No

This camper has another dietary issue ( ) Yes ( ) No

Please explain below

Does your child have a severe food allergy that requires an epipen or benadtyl ( ) Yes ( ) No

Please explain below

Page 2 of 3 If your child will be taking medication while at an overnight camp, the prescribing physician must provide sign off on all medications, including over-the-counter medications. Campers are NOT ALLOWED to hold onto medication while at camp. ALL medications must be submitted to the Health Director of the camp for proper storage and administration. If your child is found in possession of medication, either prescription or over-the-counter medication, parents will be called for immediate pick up from camp. At camp check-in, ALL prescription and over-the-counter medications along with a completed MEDICATION form must be submitted to the Health Director. Prescription medications must be in their original containers bearing the pharmacy label and have specific instructions for use (Child’s name, dosage, # pills inside, prescribing practitioner, pharmacy name & address, filler's initials, serial #).

Self-Administration: A self-administration process is used on NY overnight camp programs. Self-administration of medications will only be allowed for those individuals determined to be "self-directed". Determination as to whether or not a camper should be considered for self-administration will be conducted by the Health Director or designee and will be based on the camper's ability to correctly identify the medication, dosage and reason for need.

At the current time of registration, will the camper be required to take any prescription medication while attending camp?

( ) Yes ( ) No

At the current time of registration, will the camper be required to take any over the counter medication while attending camp?

( ) Yes ( ) No

I understand that all medication must be submitted to the health director at check-in with a completed medication form signed by a doctor.

( ) Yes ( ) No

The medication form, which needs to be signed by a doctor, will be sent to you following registration

Please explain below

I understand that you will make every reasonable effort to reach me or the other listed emergency contacts for Participant provided by me in the event the Participant is injured while participating in the Camp or any other Event. However, in the event I or any other designated emergency contact cannot be reached, and in the event of any emergency in all cases, I hereby consent on behalf of all Participant Parties for the Participant to receive emergency medical treatment from a doctor or athletic trainer if needed. I further agree to be responsible financially for the cost of each assistance and/or treatment

Name of Parent/Guardian (please print)

Signature of Parent/Guardian Date

Page 3 of 3