Microsoft word - camper health form 2013.doc

CAMP ABK - CAMPER HEALTH FORM
FOR OFFICE USE ONLY
Cabin # ____
For use by Camp ABK’s Health Personnel to best care for your child
CAMPER’S HEALTH INFORMATION
Camper Name:
Health Ins. Co. & # (if applicable): Please check any health issues this camper has: q ADD/ADHD q Behaviour q Homesickness q Other: __________________________ Details: ______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Allergy Information:
Insects - q Yes or q No Details: ___________________________________________________________________________
Food - q Yes or q No Details: ___________________________________________________________________________
Penicillin - q Yes or q No Details: ___________________________________________________________________________
Other - q Yes or q No Details: ___________________________________________________________________________
Does your Child have an epi-pen? q Yes or q No If yes, your child must bring two epi-pens to camp (one kept by nurse, one on person)
Dietary Concerns: Camp ABK accommodates medically-related dietary needs, not lifestyle dietary choices (ie.Vegetarian/organic foods)
Immunization History: Up to date? q Yes or q No Date of last Tetanus Toxoid booster: ___________________________________
Can the camper participate fully in the program? q Yes or q No If no, please explain on a separate sheet of paper.
Does the camper receive Resource/Special Education assistance in school? qYes or qNo
If yes, please describe: ____________________________________________________________________________________________
____________________________________________________________________________________________
List All Medication (including vitamins) being brought to camp:
MED. NAME DOSAGE FREQUENCY/TIMES
________________________________ ___________________________________ __________________________________
________________________________ ___________________________________ __________________________________
________________________________ ___________________________________ __________________________________
All medication/vitamins are to be kept in the Nurse’s Cabin and administered by our staff, with the exception of inhalers which may be kept
on a camper’s person. For medications that are administered by injection, the camper must be able to self administer with supervision.
★★★★ ALL MEDICATION MUST BE IN ORIGINAL PHARMACY CONTAINTERS!!! ★★★★ Over-The Counter Medication: Campers are discouraged from bringing over-the-counter medication (ie. Tylenol, Gravol, cold meds);
Camp ABK is well-stocked and the Camp Nurse can administer these if needed.
List any over-the-counter medication you DO NOT want our nurse to provide if needed: ________________________________________
Lice: Campers are checked for lice at the beginning of each camp session. If a camper is found to have lice/eggs/nits, it is the
parents’ responsibility to treat. Campers must be lice/eggs/nits-free before he/she is allowed into the program.
CAMP AUSH-BIK-KOONG PROVIDES FIRST AID ONLY.
CONSENT TO TREATMENT
1. To the best of my knowledge, my child is in good health and has not been exposed to any serious and/or infectious disease, including lice,
in the past four weeks. If he/she becomes exposed to any serious/infectious disease between now and the time of departure for camp, I
understand that Camp ABK must be notified.
2. I authorize staff of Camp Aush-Bik-Koong to provide medical attention to my child, if needed. I agree to accept financial responsibility for
any medical expenses in excess of the benefits allowed by Provincial health and/or other insurance plans where: 1) the health and well-being
of the applicant is involved; 2) The medical advice has been such that further service is required, services that require the consent of the
parent(s)/guardian(s); 3) Where all attempts to contact the parent(s)/guardian(s) have failed, or where, due to the nature of the emergency,
there is insufficient time to contact such parent( s)/guardian(s), it shall be at the discretion of the Camp Director as to what steps are taken
for the welfare and safety of the applicant.
3 In the case of surgical emergency and we are not available for consultation, I hereby give permission to the physician selected by the
Camp Director or Designate to hospitalize, secure proper treatment for and to order injections, anesthesia or surgery for my child as named
above.
3. I hereby give permission for Camp Aush-Bik-Koong’s Health Personnel to administer over-the-counter medication in case of minor injury
and/or illness during my child’s stay at Camp ABK. I also give permission for Camp Staff to provide Standard First Aid to my child as
appropriate.
4. I give permission for Epinephrine to be administered as ordered by a physician to my child in case of anaphylactic (serious allergic)
reaction.
5. I agree that all the information given on this form is complete and accurate.
SIGNATURE REQUIRED TO PROCESS REGISTRATION
I have read, understood, and accepted the consent to treatment as stated above. The information I have provided is true and accurate.

Source: http://www.buildyourownwebsite.ca/websites/campabk_com/files/Camper%20Health%20Form%202013.pdf