√CAMP HAIASTAN HEALTH RELATED FORMS CHECKLIST

√CAMP HAIASTAN HEALTH RELATED FORMS CHECKLIST
Parents please note that all health related forms below except the MEDICATION AUTHORIZATION FORM are REQUIRED FORMS.
Completed ORIGINALS must be in our office no later than 2 weeks prior to your camper’s session. Faxed forms will not be accepted.
These forms and the information contained on them are kept in strict confidence by the camp administration, however they are
absolutely mandatory for us to be able to offer the highest level of health and medical attention to your child in the event that it is
necessary. You are required to submit all information asked for completely. Administrative staff who can review these forms:
Executive Director, Camp Director, and Camp Nurse. Federal HIPA Regulations mandate that these forms are kept under lock and
key in the Health Center to protect privacy.
______HEALTH HISTORY FORM 1 – This form must be completed by a parent or legal guardian NEVER A CAMPER
(incomplete Health History Form 1 can cause refusal or delay admittance to camp):
Page 1:
• Attach a 2”x 2” recent photo of your camper for positive identification of your child if hospital care or
medication dispensation is necessary – IDENTIFICATION CONFUSION CAN BE FATAL
• Complete all sections; Allergies, Dietary & Restriction information is very important – be complete please.
• You must include a photocopy of the front and back of your health insurance card.
• Parent or Guardian must sign & date Authorization Statement.
Page 2:
• Immunization History must be complete. If you do not have your child’s immunization history, please consult
your pediatrician for this information. An Immunization History print-out from your pediatrician’s office
attached is acceptable. Please note Mass. Immunization requirements below.
• You must check if your camper will or will not take medications while at camp. If so, fill in the medication
schedule accurately. Medication mis-information can be fatal.
• Cross out non-prescription medications that you DO NOT don’t want your child to be given.
Page 3:
• General Health History and Mental, Emotional & Social Health information about your child is important.
Please don’t hesitate to use an additional paper if necessary. Remember, this information along with all of
your child’s health records are kept confidential.
• Knowing your child’s Health Care Provider information is necessary.
• Feel free to provide any other information you feel is important regarding your child’s health. Use an
additional paper if necessary
Page 4: For Camp Haiastan use only, please submit.
______CAMPER HEALTH-CARE RECOMMENDATIONS by LICENSED MEDICAL PERSONNEL FORM 2 (incomplete
information on Form 2 can cause refusal or delay admittance to camp):
•
•
•
•
This form must accompany Health History Form 1 (above).
A signed doctor’s office file print-out with the same information can be substituted for Health Form 2
Information for this form must be supplied by a licensed medical person, we recommend your child’s
examining physician.
Licensed provider must sign this form. Note: Your child is required to have a physical exam within 24 months
of camp attendance.
-OVER-
______CONFIDENTIAL INFORMATION FORM (3 pages total –Page 1 & 2 completed by you, Page 3 for Camp Haiastan use
only. Please submit all 3 pages)
______MEDICATION AUTHORIZATION FORM (Optional - submit ONLY if your camper will bring medication to camp,
prescription or over-the-counter of any kind, and will take these medications under the supervision of our Nurse.)
PLEASE NOTE MASSACHUSETTS HEALTH & IMMUNIZATION REQUIREMENTS
PLAN AHEAD! Your camper’s HEALTH HISTORY FORM 1 & CAMPER HEALTH-CARE RECOMMENDATIONS by
LICENSED MEDICAL PERSONNEL FORM 2 are due not later than 2 weeks prior to his/her camp session. We are required by
state regulation to refuse any camper without proof of a physical examination within the 24 months previous to camp attendance
as well as required immunizations.
Massachusetts Required Immunizations (regardless of what your state or country requires):
•
•
•
•
MMR (Measles, Mumps, and Rubella)
Polio
DTP (Diphtheria, Tetanus, and Pertussis)
Hepatitis B
STRICT REQUIREMENTS:
An Immunization History must be recorded on Health History Form 1 (a separate immunization record from your
pediatrician attached to Health History Form 1 is acceptable.)
The date and result of a physical examination must be recorded on Health Form 2 (a separate attached office file printout signed by the examining physician with physical exam record can be substituted for Health Form 2.)
Check all submitted health forms for required parent and physician signatures.
Remember, we must have ORIGINALS of all required forms not later than 2 weeks prior to your camper’s session.
Faxed forms, unsigned forms and incomplete forms will not be accepted.
CAMP HEALTH
Attach a 2x2 Photo Here
HISTORY FORM 1
Developed and reviewed by:
American Camp Association,
American Academy of Pediatrics
Council on School Health, &
Association of Camp Nurses.
Camper Name__________________________________________________________________________________Session___________________________
Last
First
FORM #9 REQUIRED
5. Does this camper use an individualized learning plan at school?............................................................................................................... o Yes
Please explain “Yes” answers in the space below, noting the number of the questions. The camp may contact you for additional information.
o No
Camper Name______________________________________________________________________________________________________Session___________________________________________
Last
First
CAMPER HEALTH-CARE
RECOMMENDATIONS by LICENSED
MEDICAL PERSONNEL FORM 2
Developed and reviewed by: American Camp Association,
American Academy of Pediatrics Council on School Health, &
Association of Camp Nurses.
FORM #10 REQUIRED
REQUIRED FORM – SUBMIT FOR EACH CAMPER
CAMP HAIASTAN OVERNIGHT CAMP CONFIDENTIAL INFORMATION FORM
Parents must complete this form without help from their child. (We know you can do it!) This form is reviewed by our Camp Nurse and
Administrative staff and is filed under lock and key in the Health Center. Your complete and forthright responses are necessary and
required to assist us in insuring that your camper has a successful and enjoyable camp experience. Please use a separate sheet
of paper for your responses if space does not permit on this form.
Camper Name:_______________________________________________________ Birth Date__________ Age At Camp_______
(mm/dd/year)
Health Center
Use
Address:__________________________________________ City/State/Zip:___________________________________________
Father Full Name:__________________________________________________________________________________________
Mother Full Name: _________________________________________________________________________________________
If Camper resides with one parent or guardian give that name: _______________________________________________________
Home Phone: (____) ______________________Parent Email: ______________________________________________________
Father Cell Phone: (____) __________________________Mother Cell Phone: (____) ____________________________________
Father Work Phone: (____) _________________________ Mother Work Phone: (____) __________________________________
Parent or guardian Address & Phone during camper attendance (if different than above):
_________________________________________________________________________________________________________
Emergency Information: In the event of an emergency, we will contact a parent. Please provide an additional contact person who
has agreed ahead of time to make decisions regarding your child if we are unable to reach a parent.
Emergency Contact Name: __________________________________________________Relationship_______________________
Home Phone: ________________________ Cell Phone: ________________________ Work Phone: ________________________
Has camper been to a overnight camp previously?_____ (yes/no) If yes, where & when?__________________________________
_________________________________________________________________________________________________________
Camper’s favorite activities/interestes?___________________________________________________________________________
Any particular activities camper dislikes? ________________________________________________________________________
Does camper have to be prodded (yes/no)?________ Slow Dresser?_________ Slow Eater?___________
Is camper oversensitive (nickname, weight, etc.)? Explain please: ____________________________________________________
_________________________________________________________________________________________________________
What are camper’s sleep habits?_______________________________________________________________________________
Is camper subject to sleepwalking/nightmares? (yes/no)________ Explain if yes__________________________________________
_________________________________________________________________________________________________________
Is camper a bed wetter? (yes/no)______ (If so, kindly send rubber sheet/plastic mattress cover – handled confidentially by staff)
FORM #11
REQUIRED
(OVER)
CAMP HAIASTAN CONFIDENTIAL INFORMATION FORM (cont.)
Have there been any changes, difficulties, or crises in the family that have been emotionally upsetting that we should be aware of?
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Does camper have any particular fears? _______________________________________________________________________________
Are there any dietary restrictions or diagnosed food allergies (yes/no)? ____ If yes, please describe: ________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Please share information about professional diagnosis as well as your own comments regarding your child’s developmental history within the
realms of PHYSICAL, MENTAL, EMOTIONAL, BEHAVIORAL & EDUCATIONAL. Describe management plans and support needed from the
camp to complement management plans:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Does your child have any bathroom or shower room fears or problems? (children are always supervised in the shower room) (yes/no)______
If yes, please describe: _____________________________________________________________________________________________
________________________________________________________________________________________________________________
Does your child have a fear of the swimming pool? ____ (yes/no) Highest level earned in Red Cross/YMCA Swim Prog. if known?_________
________________________________________________________________________________________________________________
Please check (√) below which swimming lesson approach you want applied to your child (our swim instructors are trained never to coerce a
camper): ___ Strongly encourage swim instruction ___Mildly encourage swim instruction
√ Check the characteristics below that you have experienced in your child otherwise leave blank:
Finishes what is started: __________ Alert: __________ Moody: __________ Obedient:__________
Team Worker: __________ Easy going: ___________ Retiring: __________ Easily Led__________
Cheerful: __________ Sensitive: __________ Strong Willed: __________ Homesickness: ___________
Please share any other comments you wish or information you feel would be helpful to us regarding your child?
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
RETAIN A COPY FOR YOUR RECORDS
THIS PAGE FOR CAMP HAIASTAN HEALTH CENTER STAFF USE ONLY (please submit with your health forms)
NURSE ARRIVAL & EXIT SCREENING DOCUMENTATION
Arrival screening date & time_________________________________________________________________________________
Camper screened by whom? _________________________________________________________________________________
•
Any updates to HEALTH HISTORY FORM 1?
____No ____Yes as noted below
•
Any updates to HEALTH HISTORY FORM 2?
____No ____Yes as noted below
•
Any signs/symptoms of illness (flu, head lice, etc.) or injury?
____No ____Yes as noted below
•
Any medications given to Nurse?
____No ____Yes as noted below
(A separate MEDICATION AUTHORIZATION FORM must be completed)
•
Any special health related needs requested for this child while at camp? ____No ____Yes as noted below
Exit screening date & time _______________________________________________________________________________
Screened by whom? _____________________________________________________________________________________
Left camp this day with no reported injury or illness signs/symptoms
Left camp this day with the following problem/concern: ______________________________________________
______________________________________________________________________________________________________
Person(s) who was told about this problem/concern: ____________________________________________________________
Health record closed by (signature): _________________________________________________________________________
OPTIONAL FORM – SUBMIT ONLY IF YOUR CAMPER WILL BRING MEDICATIONS, PERSCRIPTION OR OVER-THE-COUNTER OF ANY KIND, AND
WILL TAKE THESE MEDICATIONS UNDER THE SUPERVISION OF OUR NURSE
CAMP HAIASTAN MEDICATION AUTHORIZATION FORM
•
•
•
•
Complete this form if your camper brings any prescription or over-the counter medications.
Submit with other Health Forms no less than two weeks prior to your camper’s session.
State regulation requires medications must be in original containers with drug name, size, dosage instructions, physician
name & contact information and camper’s name on the label NO EXCEPTIONS. Meds that do not meet this requirement
will not be accepted by our staff.
Please do not send extra meds “just in case”. Exact dosage requirements must be carefully monitored by our staff.
Health Center Use
NOTE: THIS FORM TO BE KEPT WITH CAMPER’S CONFIDENTIAL MEDICAL RECORDS.
Camper Name: ____________________________________________________________________________
Session(s): ____________ Cabin No.____________ Counselor_____________________________________
I, ____________________________________________________, hereby give permission to the Nurse/
(Print parent or guardian name)
Health Officer to administer the prescribed medication(s) listed below to my child.
Signed:______________________________________________________ Date:___________
(Parent or Guardian)
Signed:______________________________________________________ Date:___________
(Camp Haiastan Nurse/Health Officer)
List Medication(s) & Dosage (use back of page if necessary):
#1
#2.
#3
FORM #12
OPTIONAL
RETAIN A COPY FOR YOUR RECORDS