1. IMMUNIZATION HISTORY


CAMP NUNNY CH-HA HEALTH INFORMATION FORM 2007 FOR GIRLS CAMP
(Not necessary for Mother/Daughter Camp)
For Camp Use:

Cabin Assigned ____
Note to contact person. Please duplicate this form for each camper.

 

 
ã DO NOT MAIL THIS FORM. BRING IT WITH YOU TO CAMP.
 

Please check the week your camper is attending camp:
 Girls’ Week-long Camp (1) June 11-15 ____
Girls’ Week-long Camp (2) June 18-22 ____ Girls’ Week-long Camp (3) June 23-29 ____
 
Name_____________________________________ Grade ______ Birth Date _____________ Age _____ Weight______
Last            First         Next Fall
 
Parent or Guardian _________________________________________________ Home Phone (_____) _______________
                                                   Area   Number
Home Address ______________________________________________________________________________________
          Street & number City State Zip Code
Email Address
 
Father’s Work Phone (_____) _______________     Mother’s Work Phone (_____) _______________
    Area   Number                           Area   Number
 
List two other persons who would know where parents can be reached or could get word to them in case of emergency:
 

1. Name ___________________________________________- (_____) ________________

Area    Number
 

2. Name ___________________________________________- (_____) ________________

Area    Number
 
Do you have health insurance coverage?     o Yes     o No
 
If “Yes”, give name of carrier ____________________________________________  Policy # ______________________
 
Doctor’s name ____________________________________________________________  (_____) ___________________
                      Area   Number


HEALTH HISTORY: (Check Yes or No)
 
 
DOES YOUR CAMPER HAVE ALLERGIES THAT THE NURSE NEEDS TO KNOW ABOUT?    Yes No
 
IF SO, WHAT? __________________________________________________________________________________________________________
 
Other current physical, mental or psychological conditions or behaviors parents need to share with the camp nurse and staff.
__________________________________________________________________________________________________
 
Has the camper started menstruation yet? ______ If so, is her period likely to come during camp? __________________
Describe any activities which the camper should b exempted for health reasons__________________________________
 
IMPORTANT: Please notify the camp if this camper has been exposed to any communicable disease during the three weeks prior to camp attendance. Suggestions from parents’:
 
________________________________________________________________________________________________
 

(over – WE MUST HAVE BOTH SIDES)
 
 
 
IMMUNIZATION HISTORY

While Immunizations are not required for camp,

    IT IS IMPORTANT THAT AN IMMUNIZATION RECORD BE ATTACHED. This
Information is given to the camp doctor in case you camper needs medical attention.
 

 
RECOMMENDATIONS AND RESTRICTIONS WHILE IN CAMP
        
Special Diet _____________________________________________________________________________________
Special medicine (give name of medicine) _____________________________________ Is parent sending it? ______
MEDICATIONS BROUGHT TO CAMP MUST BE IN ORIGINAL CONTAINER WITH INSTRUCTIONS ATTACHED.
Please note this includes vitamins and any over the counter medications.
Permission is given for my child to receive over the counter medication YES _____ NO ______
Any specific activities that need to be restricted _______________________________________________________
Swimming, diving, other?__________________________________________________________________________
   

 
Has the camper been to camp before Yes____ No____ If yes, when?______ Where__________________________
 
Participation in waterfront activities will be on the basis of swimming ability. Each child will be given an opportunity to demonstrate swimming abilities upon arrival at camp. Competent trained instructors will lead other activities. A camper’s safety is always the main concern.
 
 
 
PARENTS AUTORIZATION
 
This health history is correct as far as I know, and the person herein described has permission to engage in all prescribed activities, except as noted.
In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injections, anesthesia or surgery for my child as named above.
 
Signature of parent or guardian__________________________________________Date_______________

 
 
 
 
 
 

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