Health Center Requirements Academy by the Sea/Camp Pacific

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1 Health Center Requirements Academy by the Sea/Camp Pacific The information in this health packet is used to assist our health care professionals in providing proper care for your child. In an effort to avoid any delays for you and your child on registration day please submit all health forms by June 1 st. If you are not able to meet this deadline or if you are registering late please contact Summer Programs immediately so that we may assist in expediting this process. It is advised you keep a copy of these records in case they are not received by mail or fax. Thank you in advance for your cooperation. FORMS MUST BE COMPLETED PER THE FOLLOWING INSTRUCTIONS: Pages 1, 2, and 3 Consent To Treat and Health History To be filled out and signed by parent/guardian. Pages 4 and 5 Physical Examination Forms To be filled out, dated, and signed by a physician. The examination is to have been performed within the past 24 months. Returning participants may use last years physical if it is within 24 months; however the form must be reviewed, signed, and dated for the current year by the physician stating there are no changes in their health. Page 5 Administration of Medication To be filled out, dated, and signed by a physician. This form is required for all participants even if no medications are taken. Participants must list all medications, including all prescription, over-the-counter, and vitamins. All medications are kept and stored in the health center for the safety of all participants. All medications including over the counter and vitamins are to be turned into the Health Center during registration. Please have medications easily accessible to turn in at the registration table, you will not be able to complete the registration process until medications are turned in. Participants are not allowed to self medicate. Keep all medication in its original packaging with the name of the participant, physician, medication, and with direction of dosage. No baggies, pill box containers, or expired medication will be accepted or administered. Samples must be accompanied with written instruction from the physician. Foreign medications must have a written translation with the name of the medication and directions from a physician or pharmacist. Page 6 Notice of Privacy Practice - Academy HIPPA Policy: Parents/Guardians please read and sign. MEDICAL INSURANCE through a U.S. company is required for all participants and proof must be provided for attendance. International participants must purchase the temporary policy provided by Academy by the Sea/Camp Pacific. Domestic participants with no medical insurance must purchase a temporary policy before the enrollment date. If you need assistance in finding an insurance carrier please call the office for a list of carriers. Attach a photocopy front and back of the participant s insurance card. IMMUNIZATION RECORDS are required for all participants by law. Immunizations must be complete and up-to-date. See outline below. Please attach photocopy of the participant s immunization records. INTERNATIONAL PARTICIPANTS must have had a TB test performed in the last year with copies of the results provided to the Health Center. If the TB test is positive, an X-ray report stating an x-ray was performed and is normal must be provided to the Health Center. This is also required for those who have had the BCG Vaccine. If you have any questions regarding the requirements please contact the camp nurse. VACCINE AGE REQUIREMENT Polio doses: 3 if one was on or after the second birthday DTaP, DTP, TD, or DT 7 and older 4 doses: 3 if one was on or after the second birthday. If last dose was before second birthday td booster is needed DTaP, DTP, TD, or 7 grade 1 dose of td booster, if more than 5 years have passed since last dose DT MMR 1-6 and dose on or after 1 st birthday grade MMR 7 grade 2 doses both on or after the 1 st birthday Varicella Out of state 1 dose under 13years 2 doses are needed if immunized on or after 13 th birthday Hepatitis B 7 grade 3 doses The California School Immunization Law allows a child to be exempt from the immunization requirements for personal beliefs or medical reasons. If your child is exempt from immunization, please let us know and we will provide you with a waiver to sign and return. For further information, contact your physician, local health department, or our health center. FOR ALL HEALTH RELATED QUESTIONS PLEASE CONTACT OUR HEALTH CENTER. PHONE: (760) FAX: (760)

2 Consent For Treatment (Page 1 of 6) SELECT THE PROGRAM(S) YOU ARE ATTENDING THIS SUMMER: Academic C-PREP Camp Pacific Surf Camp Sport Camp Camp Challenge CIT The information on this form is part of the enrollment process; it is gathered to assist us in identifying appropriate care. This form is to be filled in by the parent/guardian of participants with the exception of the Physician s Examination section. Male Female Participant: Birth Date / / First Name Last Name M.I. Month / Day / Year Home Address: 1 st Contact - Relationship to Participant: Mother Father Other Ms. Mr. Mrs. First Name Last Name Same as Above Home Address: Home Number Cell Number 2 nd Contact - Relationship to Participant: Mother Father Other Ms. Mr. Mrs. First Name Last Name Same as Above Home Address: Home Number Cell Number 3 rd Contact - Relationship to Participant: Mother Father Other Ms. Mr. Mrs. First Name Last Name Same as Above Home Address: Home Number Cell Number MEDICAL INSURANCE through a U. S company is a mandatory requirement for entrance into the program. Is participant covered by Family medical insurance? Yes No* *Participants with no U.S insurance must obtain coverage prior to the program start date. Domestic participants must obtain a temporary policy through their own means and international participants must enroll in the Academy s temporary medical insurance (see contract for details). A photocopy of the front and back of the participant s insurance card is required for attendance. Insurance Carrier: Policy #: Group #: Address: Phone #: Policy Holder: Family Physician: Phone #: Fax #: Address: It is recommended that all regular dental care be done prior to attending the program. Only emergency dental care will be provided. CONSENT FOR TREATMENT: Permission for Emergency Treatment I hereby give permission to the medical personnel selected by Academy by the Sea/Camp Pacific and/or its authorized representative to: administer medication; order x-rays; order routine tests; render treatment; provide or arrange necessary transportation for the participant; and obtain and release any records and medical information necessary. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Academy and/or its authorized representative to secure and administer treatment, including hospitalization, for the person named above. I authorize any hospital or health care practitioner rendering care necessary under the circumstances for the person names above and to provide copies of medical records and to share clinic information with the Academy and/or its authorized representative. This entire completed from may be photocopied for trips or emergencies off campus. Signature (Parent or Guardian Signature) Date

3 Health History (Page 2 of 6) The following information must be filled in by the parents/guardian. The intent of this information is to provide health care personnel your child s background to provide appropriate care. Provide complete information so we can be aware of the participant s needs. Keep a copy of the completed forms for your records. Please notify health center personnel of any changes prior to arrival. 1 2 Recent injury, illness or infectious diseases? Chronic or recurring illness or condition? YES NO YES NO 23 Migraine headache? 24 Chest pain? Before or after exercise? 3 Hospitalization? 25 Ever passed out during or after exercise? 4 Surgery? 26 Ever been dizzy during or after exercise? 5 Cancer? 27 Heart palpitation or rapid heart rate? 6 Diabetes? 28 Diagnosed with a heart murmur? 7 Mononucleosis in the past 12 months? 29 High blood pressure or high cholesterol? 8 Asthma? Last attack: 30 9 Shortness of breath? 31 Family member or relative die of health problems or sudden death before the age of 50? Chronic diarrhea, constipation or stomach problem? 10 Recurring colds and/or chronic cough? 32 Hernia? 11 Sinus problems? 33 Genital or urinary problems? 12 Hay fever or environmental allergies? 34 Sexually Transmitted Disease? 13 Frequent ear infections? 35 Problems with joints (e.g. knees or ankles)? 14 Seizures? Last episode: 36 Back problems? 15 Other Neurological disorder? 37 Hearing impairment? 16 Head injury? Loss of consciousness? 38 Eye or vision problems? 17 Dizzy or passed out? History of anxiety, depression or emotional difficulties? History of eating disorder? Recent gain/loss of weight? Wear glasses, contacts or protective eyewear? 40 Orthodontic appliance brought to school? 41 Tooth or Gum problems? 20 Trouble sleeping? 42 Skin problems (e.g. itching, rash, acne)? 21 History of bed-wetting? 43 History of drug or alcohol use/abuse? 22 Frequent headaches? (non-migraine) 44 Treated for drug or alcohol use/abuse? 45. Other: * If the candidate wears corrective lenses, please provide a copy of the prescription to facilitate repair or replacement, if needed.

4 Health History (continued ) (Page 3 of 6) Please explain any yes answers, noting the number of the question: Additional information about behavior and physical, emotional, or mental health about which Academy by the Sea/Camp Pacific should be aware: Please indicate any dietary restrictions: Explain any restrictions to activity (e.g. what cannot be done, what adaptations or limitations are necessary): Date of last Tetanus Booster \ \ Date of last Physical \ \ ALLERGIES: List all known allergies and describe reactions and management of the reaction. Medication Allergies List Food Allergies List Other Allergies List (include insect stings, hay fever, asthma, animal dander, etc.) Parent/Guardian Authorization: This health history is correct and complete as far as I know, and the person herein described has permission to engage in all activities except as noted. Print Name Signature Date

5 Physical Examination (Page 4 of 6) PHYSICAL EXAM IS REQUIRED FOR ALL PARTICIPANTS. Exam must be completed within 6 months of enrollment of the current year. A licensed medical practitioner must complete this form within 24 months of program start date. Note: a TB Mantoux Test is required for international participants. Due to the boarding environment, it is recommended that the need for a Meningitis vaccine be discussed at this physical. Physical Examination: Complete a thorough review of systems. Please remark as OK or describe abnormalities in detail. Any necessary treatment or referrals should be completed prior to attendance. Height Weight Blood Pressure Pulse Head Eyes Ears Nose Throat / Mouth Neck Thyroid Neurological Lungs Heart Abdomen Genitalia / Hernia Back Shoulder / Arm Extremities Elbow / Forearm Wrist / Hand Hip / Thigh Knee Leg / Ankle Foot Skin BMI Nutritional Status Anxiety Depression ADD/ADHD Other Psych Problem VISION: R 20/ L 20/ Corrected: Yes No Comments: HEARING: Within Normal Range: Yes No Abnormalities? SCOLIOSIS: Normal: Yes No Abnormal/ Degree of Curvature: IMMUNIZATIONS A copy of the immunization record is mandatory for admission. Please review participant s immunization record and administer any vaccines needed to adhere to the California State guidelines. Date of last tetanus booster: / / Has the participant had any of the following illnesses? Chicken Pox Measles Mumps German Measles Hepatitis TB Mantoux Test (International participants only) A TB test within twelve months is mandatory including those who have had the BCG vaccine. Test Date \ \ Results Reading \ \ (within Hours) Positive Negative induration mm *If skin test is positive a Chest X-Ray must be performed and this area completed Film Date \ \ (do not send copy of x-ray) Impression: Normal Abnormal Participant is free of communicable Tuberculosis: Yes No The participant is under the care of a physician for the following conditions: MEDICATIONS: Does the participant take any medication including routine, OTC S, and supplements? *Yes No (*see pg. 5) Current treatment at the time of this report includes: RESTRICTIONS: Please describe in detail any condition that would prevent or limit full participation in all activities including running, swimming, surfing, sports, and amusement rides: Treatment to be continued while at the Academy: Additional information for health care staff: Is the above applicant able to participate in physical activity? YES NO Physical Exam Date: / / Signature of Physician Date Printed Name Title Address Phone Fax

6 Administration of Medication (Page 5 of 6) Please list ALL medications (including vitamins and over-the-counter drugs) to be taken at the Academy; the name of the medication, the dosage, and the frequency of administration. All medication, including vitamins and over-the-counter are kept and stored in the Health Center. Please keep medications in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), medication name and dosage, participant s name, and expiration date. All prescription medications will need to be refilled by the parent/guardian. The Health Center maintains a supply of over the counter medications for complaints of headache, congestion, cough etc. NO, this person does not take medications on a routine basis. YES, this person takes medications as follows: Med #1 Dosage Specific times taken each day Reason for taking Med #2 Dosage Specific times taken each day Reason for taking Med #3 Dosage Specific times taken each day Reason for taking Med #4 Dosage Specific times taken each day Reason for taking Med #5 Dosage Specific times taken each day Reason for taking Attach additional pages if needed. PHYISCIAN S AUTHORIZATION Signature of Physician Date Printed Name Title Address Phone Fax FOR NURSE ONLY. TO BE COMPLETED BY MEDICAL STAFF AT REGISTRATION. SCREENING RECORD Date Screened Time am pm Medications Received Updates/additions to health history noted: Yes No None required Current health needs identified Observational notes Screened by

7 Notice of Privacy Practice Academy HIPPA Policy (Page 6 of 6) PARTICIPANT Last Name PARTICIPANT First Name THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT ABOVE NAMED PARTICIPANT MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY BEFORE SIGNING. The Academy Health Center, as a provider under the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ), complies with all regulations designed to protect the privacy of individual health information. Understanding Your Health Record/Information - A record is made of every visit to a health care provider, including the ANA Health Center. Typically this record contains the patient s symptoms, examination/test results, diagnoses, and treatment. This medical or health record is used to plan patient care and permit communication among health professionals, to document care received and verify services provided, to provide data for public health officials, and to improve health services. Your Health Information Rights - Although the health record is the physical property of the AN Health Center or the entity that compiled it, the information belongs to the patient. As the patient s legal guardian you have the right to request a restriction on certain uses and disclosures, to obtain a copy or to request (in writing) to amend the record, to obtain an accounting of disclosures, to request communication of the health information by alternative means, and to revoke your authorization to use/disclose health information except to the extent already done. The Academy Health Center Responsibilities - We are required by law to maintain the privacy of your personal health information and to provide you with this Notice of our legal duties and privacy practices with respect to your personal health information and to have you sign a written acknowledgment that you received this Notice. You will be notified if the ANA Health Center is unable to grant requested restrictions, and accommodate reasonable requests to communicate health information by alternative means or at alternative locations. The ANA Health Center will maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard personal information. The ANA Health Center may disclose information for law enforcement purposes as required by law or in response to a valid subpoena. Persons violating the schools Privacy Policy will be subject to disciplinary procedures. The ANA Health Center reserves the right to change its practices regarding protected health information, in which case a revised privacy notice would be ed or mailed to the address you have supplied. Uses and Disclosures of Health Information - The Academy Health Center personnel will use or disclose patient health information only as needed in treatment, payment, and health care operations. In particular The ANA Health Center may, without specific additional authorization, disclose the patient s health information to any health care provider treating or otherwise rendering professional services to the patient and/or to insurers as necessary to facilitate payment for the patient s health care. Health care providers may, without specific additional authorization, disclose information to The ANA Health Center as needed for the patient s care and treatment. With the exceptions described in this notice and as provided by law, The ANA Health Center will not use or disclose health information without authorization. We may disclose your protected health information in the following situations without your authorization: As required by Judicial or Administrative Proceedings or law enforcement officials We may disclose your protected health information to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or grand jury or administrative subpoena. Public Health Activities - We may disclose your protected health information to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability. Victims of Abuse, Neglect or Domestic Violence If we reasonable believe you are a victim of abuse, neglect or domestic violence, we may disclose your protected health information to a governmental agency, authorized by law to receive reports of such abuse, neglect or domestic violence. Health Oversight Activities - We may disclose your protected health information to a health oversight committee ensuring compliance. Specialized Government Functions - We may disclose your protected health information to units of the government with special functions, such as the U.S. Military or the US Department of State. For More Information or to Report a Problem - If you have questions, please contact the Infirmary at If you believe privacy rights have been violated, you have the right to file a complaint with the Department of Health and Human Services ( ). The Academy Health Center will not retaliate for filing a complaint. Acknowledgement of Authorization to Use and Disclose Health Information I understand and agree that by enrolling at Academy by the Sea/Camp Pacific, the participant named in this Health Form, and by my signature below, I authorize the Academy Health Center personnel to use and disclose the patient s protected health information as needed in treatment, payment, and health care operations. The Academy Health Center personnel may, without my specific authorization, disclose the patient s health information to any health care provider treating or otherwise rendering professional services to him and to insurers as necessary to facilitate payment for services. I understand that information received pursuant to this authorization may be disclosed by the recipient and might lose its protected status. I understand that I may revoke this authorization at any time by written notice to the Academy Health Center. I have read the above and have received a copy of this Notice of Privacy Practice. Signature of Parent/Guardian: Date:

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