Health Form

Health Form

Health Form PDF Download

THIS FORM IS TO BE COMPLETED AND SENT TO CAMP. Camper’s Name (last) (first) (middle)

Sex Age Birth date

Parent/Guardian Name Part One --- Parental Authorization I understand and certify that my child’s participation in the summer camp program is completely voluntary. I understand that certain hazards and dangers are inherent in the camp program, and I acknowledge that although Camp Kaleidoscope has taken measures to minimize the risk of injury to camp participants, Camp Kaleidoscope cannot guarantee that the activities will be free of accidents or injuries. Furthermore, I have instructed my child in the importance of abiding by the camp’s rules and procedures for the safety of camp participants. I understand that parents are contacted in the event their child receives professional medical attention. In the event that I cannot be reached in an EMERGENCY, I hereby give permission to the attending physician secured by Camp Kaleidoscope, to secure proper treatment for, and to order injections, anesthesia, or surgery for my child. Signature of Parent Date If you carry medical insurance, please indicate: Insurance Carrier Policy # Insurance Carrier Phone Number ( ) Policy Holder’s Name SS# Part Two --- Health Information Basic Health History: Please check any that apply:
_ frequent ear infections
_ asthma
_ bleeding disorders
_ diabetes _ heart defect
_ convulsions
_ epilepsy Allergies:
_ penicillin
_ serious poison ivy
_ bee stings _ aspirin
_ food allergies (specify below) other (specify):

Which of the following over the counter medications may we administer to your child? _ acetaminophen
_ ibuprofen
_ benadryl Immunizations: All immunizations must be up to date, or a written refusal based on beliefs as granted by Massachusetts state law. Indicated dates of basic immunization or most recent booster.
____________DPT ___________Polio __________Measles
____________Current Tetanus (If date cannot be supplied, please initial this statement: “In case of an emergency, the attending physician may administer a tetanus booster.”) Operations, Serious or Chronic Illnesses: Dietary Modifications While At Camp: Prescription Drugs Camper Brings to Camp: (include instructions) Part Three --- Health Examination Record This health history record is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted by me. I also attest that the person herein described has had a medical examination within the past 24 months. Physical Restrictions: Date of Last Physical Parent’s Signature Date Name & Phone # of Family Physician ( )