√CAMP HAIASTAN HEALTH RELATED FORMS CHECKLIST

√CAMP HAIASTAN HEALTH RELATED FORMS CHECKLIST
Parents please note that all health related forms below except the AUTHORIZATION TO ADMINISTER MEDICATION TO A
CAMPER 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 in them are 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 provide information requested
completely, accurately and truthfully. Administrative staff who can review these forms: Executive Director, Camp
Director and Camp Nurse. It is Camp Haiastan’s policy to protect the privacy of campers and staff members by
maintaining health related information securely in our Health Center and Main Office. We will communicate camper
and minor-aged staff health status and information only with the parent(s) or legal guardian designated. Contact
Executive Director Roy Callan at 508 520-1312 or [email protected] should you have questions or concerns.
______HEALTH HISTORY FORM 1 – CAN BE COMPLETED ONLINE, SAVED & EMAILED OR MAILED - Must be
completed by a parent or legal guardian never a camper:
Page 1:
 REQUIRED: A current 2”x 2” school full frontal face photo of your camper for positive identification of your
child if emergency response, hospital care and/or medication administration is necessary – IDENTIFICATION
CONFUSION CAN DELAY URGENT CARE AND CAN BE FATAL. Photo must be mailed, do not email.
 Complete all sections; Allergies, Dietary & Restriction information is very important – please be complete.
 REQUIRED: Photocopy of the front and back of your health insurance card (if your child is not covered by
health insurance, we will require our signed waiver and assumption of risk). Scan and email or mail your
health insurance card copy with HEALTH FORM 1.
 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 is acceptable and must include
dates of immunizations. Scan and email or mail with HEALTH FORM 1.
• Note new Commonwealth of Massachusetts immunization requirements and
recommendations at the bottom of pg. 2.
• If your child is not fully immunized to Comm. of Mass. requirements due to religious or
medical reasons, we will require our signed waiver and assumption of risk.
 Medication: You must check (√) if your camper will or will not take medications while at camp.
 Check each box of the non-prescription medications that you DO NOT want your child to be given.
Page 3:
 General Health History and Mental, Emotional & Social Health information about your child is important. Use
an additional paper if necessary – scan and email or mail with HEALTH FORM 1. 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.
CAMP HAIASTAN HEALTH RELATED FORMS CHECKLIST Pg. 2 (cont.)
______HEALTH FORM 2 CAMPER HEALTH-CARE RECOMMENDATIONS by LICENSED MEDICAL PERSONNEL –
DOWNLOAD & PRINT – CANNOT BE COMPLETED ONLINE:
 This form must accompany HEALTH HISTORY FORM 1, scan and email or mail.
 A standardized office file print-out from your pediatrician can be substituted for HEALTH FORM 2, however it
must be signed by your pediatrician and must contain the same information required on HEALTH FORM 2
and attached to our HEALTH FORM 2.
 A licensed medical provider must complete this form, we recommend your child’s examining physician.
 Note: There must be evidence that your child has had a physical exam within 24 months of camp attendance.
______AUTHORIZATION TO ADMINISTER MEDICATION TO A CAMPER FORM – CAN BE COMPLETED ONLINE, SAVED
& EMAILED OR MAILED:
 Optional - submit only if your camper will bring medications to camp, prescription or over-the-counter of any
kind including vitamins and homeopathic remedies.
 Each medication requires a separate form signed by parent or guardian – form(s) must accompany HEALTH
FORM 1 & HEALTH FORM 2. Note medication package requirements on this form.
 Insuring that the correct medication is given to the correct camper is of the highest importance.
______MENINGOCOCCAL DISEASE & CAMP ATTENDEES: COMMONLY ASKED QUESTIONS FOR PARENT REVIEW
These immunizations are required by the Commonwealth of Massachusetts for camp attendance regardless of what is
required in your state or country:
1. MMR (Measles, Mumps, Rubella):
At least 1 MMR. A second dose administered at least one month after the first dose, is required for campers
entering K-12 in the school year immediately following the camp session or, in the case of ungraded classrooms
or not attending school, the requirement for 2 doses applies to campers 5 years of age and older.
2. Polio: At least 3 doses polio vaccine.
3. DTP (Diphtheria, Tetanus, Pertussis):
At least 4 doses of DTap. One dose of Td (Tdap preferred) for campers entering grades 7 through 12. Everyone
else is required to have a dose of Td (Tdap preferred) if it has been more than 10 years since the previous dose of
Td.
4. Hepatitis B: 3 doses of Hepatitis B vaccine or laboratory evidence of immunity required.
These vaccines are recommended by the Commonwealth of Massachusetts as a measure to help prevent outbreaks of
vaccine preventable diseases at camps:
1. Campers Younger Than Age 12:
One dose of chickenpox vaccine is required for children in grades 8-12. However, beginning in fall 2011, 2 doses
of varicella (chickenpox) is required for school entry for kindergarteners and 7th graders, and healthcare provider
certified history of chickenpox disease. This 2-dose requirement is being phased in for subsequent grades during
the coming years.
2. Campers Ages 12 Through 16:
One booster dose of Tdap. 1 dose of chickenpox vaccine is required for children in grades 8-12. However,
beginning in fall 2011, 2 doses of varicella (chickenpox) is required for school entry for kindergarteners and 7th
graders, and healthcare provider certified history of chickenpox disease. This 2-dose requirement is being
phased in for subsequent grades during the coming years.
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Developed by: American Camp Association,American Academy
of Pediatrics Council on School Health, & Association of Camp
Nurses.
FORM #7 REQUIRED
Camper Name ________________________________________________________________________________________________________________________________________________________
Last
First
Session
CAMPER HEALTH-CARE
RECOMMENDATIONS by LICENSED
MEDICAL PERSONNEL FORM 2
OPTIONAL FORM – SUBMIT ONLY IF YOUR CAMPER WILL BRING MEDICATIONS, PRESCRIPTION OR OVER-THE-COUNTER OF ANY KIND
INCLUDING VITAMINS AND HOMEOPATHIC REMEDIES, AND WILL BE TAKEN UNDER THE SUPERVISION OF OUR NURSE
CAMP HAIASTAN AUTHORIZATION TO ADMINISTER MEDICATION TO A CAMPER FORM
> STATE REGULATIONS REQUIRE THIS FORM SUBMITTED FOR EACH MEDICATION THAT IS SENT WITH YOUR CAMPER <
Submit with other Health Forms no less than two weeks prior to your camper’s session
I hereby authorize Camp Haiastan to administer to my child, __________________________________________ Age:______
OFFICE USE
camper’s first & last name
the medication listed below, in accordance with *Comm. of Mass. regulation 105 CMR 430.160.
Session(s):__________ Cabin Number:___________ Counselor:_________________________________________________
Food/Drug/Environmental Allergies:_________________________________________________________________________
Diagnosis (at parent discretion):____________________________________________________________________________
Name of licensed prescriber:_______________________________________________________________________________
Name of medication:__________________________________ Dose given at camp:__________________________________
How administered:_____________ Frequency:____________ Date ordered:____________ Duration of order:_____________
Quantity received:_____________ Expiration date:_____________ Storage requirement:______________________________
Specific directions (e.g. on empty stomach/with water):___________________________________________________________
______________________________________________________________________________________________________
Possible side effects/adverse reactions:_______________________________________________________________________
Parent/Guardian Signature:__________________________________________________________ Date:_________________
MEDICATION PACKAGING REQUIREMENTS: To be accepted by our Nurse, prescribed pills/tablets must be blister
packed and labeled by a pharmacy in the exact quantity prescribed for the camper’s camp stay. Prescribed liquid or
cream meds must be in original sealed pharmacy container with label. Prescribed medication labels: Camper’s name,
medication identification, dosage instructions, physician’s name and contact info and date of filling and expiration date.
Over-the-counter medications, vitamins and homeopathic remedies must be in the original manufacturer’s container
with information, instruction and expiration date label intact. NO EXCEPTIONS TO MED PACKAGING REQUIREMENTS.
*105 CMR 430.160(A)
Medication prescribed for campers shall be kept in original containers bearing the pharmacy label, which shows the
date of filling, the pharmacy name and address, the filling pharmacist’s initials, the serial number of the prescription, the name of
the patient, the name of the prescribing practitioner, the name of the prescribed medication, directions for use and cautionary
statements, if any, contained in such prescription or required by law, and if tablets or capsules, the number in the container. All
over the counter medications for campers shall be kept in the original container containing the original label, which shall include
the directions for use.
*105 CMR 430.160(C)
Medication shall only be administered by the health supervisor or by a licensed health care professional authorized to
administer prescription medications. The health care consultant shall acknowledge in writing the list of medications administered
at the camp. If the health supervisor is not a licensed health care professional authorized to administer prescription medications,
the administration of medications shall be under the professional oversight of the health care consultant. Medication prescribed
for campers brought from home shall only be administered if it is from the original container, and there is written permission from
the parent/guardian.
*106 CMR 430.160(D)
When no longer needed, medications shall be returned to a parent or guardian whenever possible. If the medication
cannot be returned, it shall be destroyed.
RETAIN A COPY FOR YOUR RECORDS
FORM #8
OPTIONAL
Provided By Mass. Dept. of Public Health For Parent/Guardian Review August 2011
Meningococcal Disease & Camp Attendees: Commonly Asked Questions
What is meningococcal disease?
Meningococcal disease is caused by infection with bacteria called Neisseria meningitidis. These bacteria
can infect the tissue (the "meninges") that surrounds the brain and spinal cord and cause meningitis , or
they may infect the blood or other organs of the body. In the US, about 1,000-3,000 people get
meningococcal disease each year and 10-15% die despite receiving antibiotic treatment. Of those who
survive , about 11-19% may lose limbs, become deaf, have problems with their nervous system, become
mentally retarded, or have seizures or strokes .
How is meningococcal disease spread?
These bacteria are passed from person-to-person through saliva (spit). You must be in close contact with
an infected person's saliva in order for the bacteria to spread. Close contact includes activities such as
kissing, shar ing water bottles, sharing eating/drinking utensils or sharing cigarettes with someone who is
infected; or being within 3-6 feet of someone who is infected and is coughing and sneezing.
Who is at most risk for getting meningococcal disease?
People who travel to certain parts of the world where the disease is very common , microbiologists, people
with HIV infection and those exposed to meningococca l disease during an outbreak are at risk for
meningococcal disease. Children and adults with damaged or removed spleens or terminal complement
component deficiency (an inherited immune disorder) are at risk. People who live in certain settings such
as college freshmen living in dormitories and military recruits are at greater risk of disease.
Are camp attendees at increased risk for meningococcal disease?
Children attending day or residential camps are not considered to be at an increased risk for
meningococcal disease because of their participation .
Is there a vaccine against meningococcal disease?
There are currently 2 types of vaccines available in the US that protect against 4 of the most common of
the 13 serogroups (subgroups ) of N. meningitidis that cause serious disease. Meningococcal
polysaccharide vaccine is approved for use in those 2 years of age and older . There are 2 licensed
meningococcal conjugate vaccines . Menactra® is approved for use in those 9 months - 55 years of age.
Menveo® is proved for use in those 2 to 55 years of age. Meningococcalvacc ines are thought to provide
protection for approximately 5 years.
Should my child receive meningococca/ vaccine?
Meningococcal vaccine is not recommended for attendance at camps. However, this vaccine is recommended
for certain age groups; contact your child's health care provider. In addition, parents of children who are at
higher risk of infection, because of certain medical conditions or other circumstances , should discuss
vaccination with their child's healthcare provider .
How can I protect my child from getting meningococcal disease?
The best protection against meningococcal disease and many other infectious diseases is thorough and
frequent handwashing , respiratory hygiene and cough etiquette. Individuals should:
1. wash their hands often , especially after using the toilet and before eating or preparing food (hands
should be washed with soap and water or an alcohol-based hand gel or rub may be used if hands are
not visibly dirty);
2. cover their nose and mouth with a tissue when coughing or sneezing and discard the tissue in a trash
can; or if they don't have a tissue, cough or sneeze into their upper sleeve .
3. not share food, drinks or eating utensils with other people, especially if they are ill.
You can obtain more information about meningococcal disease or vaccinat ion from your healthca re provider,
your local Board of Health (listed in the phone book under government ), or the Massachusetts Department of
Public Health Division of Epidemiology and Immunization at (617) 983-6800 or toll-free at (888) 658-2850 or on
the MDPH website at www.mass.gov/dph.
Provided by the Massachusetts Department of Public Health in accordance with M.G.L. c.111, s.219.
Massachusetts Department of Public Health
305 South Street, Jamaica Plain, MA 02130