Camper Name: Male Female DOB: Custodial parent(s)/guardian(s)name phone: cell # Physician Name Telephone: Exam Date: Weight: lbs.

Transcription

1 To be Completed by Physician or Licensed Medical Personnel Camper Name: Male Female DOB: Custodial parent(s)/guardian(s)name phone: cell # Page 1 2. Physician Name Telephone: Exam Date: Weight: lbs. Height: Blood Pressure / Allergies: none known Allergies To medications; To environment; Foods; Other* *List allergies & describe previous reactions Bring your own EPIPEN! if needed *Diet/Nutrition: this camper eats a regular diet; OR this camper has dietary needs/restrictions. (Parents complete dietary/allergy form) 3. Health History Please circle all current and past health issues. Respiratory Cardiac (ex: Headaches Diabetes Nose bleeds (ex: asthma) murmur) Homesickness Sleep-walking Bed-wetting Surgery Ear infections/ tubes Seizure Eating disorder Psychiatric Behavioral ADD/ADHD disorder Head Injury/ Concussion Glasses/ contacts Dental (ex: braces) Skin problems Mononucleosis in the past 12 months Crutches/ casts Difficulty during menses Other Comments/Restrictions: 4. Please list all current prescribed, as needed, & over the counter medications, supplements, vitamins or topical ointments used by the above noted minor: Medication Dosage Route Schedule *Self-Carry Please note: absolutely no prescription or over the counter medications, supplements, vitamins or topical ointments can be administered without a physician order, in accordance with NYS law. All medications sent to camp with your child must be in the original prescription container or packaging. Campers 8 years or older may self-carry only the following medications with written permission from their physician certifying that the minor has been instructed in and is capable in its use, purpose, dosage, administration & effects: Epipen, rescue inhalers, & insulin pumps. 5. Please provide a copy of immunization records or fill out IMMUNIZATION History below. Immunization Dose 1 date Dose 2 date Dose 3 date Dose 4 date Dose 5 date DTP/aP Hep B XXXXXXXX XXXXXXXX Hib XXXXXXXX MMR XXXXXXXX XXXXXXXX XXXXXXXX Pneumococcal XXXXXXXX Polio XXXXXXXX Varicella (or proof of disease) XXXXXXXX XXXXXXXX XXXXXXXX Meningococcal XXXXXXXX XXXXXXXX XXXXXXXX XXXXXXXX If camper has religious exemption from immunizations, please provide letter from parent or guardian.

2 Camper Name: DOB To be Completed by Physician or Licensed Medical Personnel 6. Please indicate approval for administration by circling yes or no in the space indicated. Page 2 Medication Route Dosage Schedule & Indications May be administered Tylenol (acetaminophen) By mouth (elixir or Per label instructions by Every 4 hours prn pain or Yes/ No age and weight tablet) fever > F Motrin (ibuprofen) By mouth (elixir, Per label instructions by Every 4 hours prn pain or Yes/ No age and weight suspension or fever > F tablets) (Benadryl) diphenhydramine HCl By mouth (elixir, tablets, or capsules). Apply topically Per label instructions by age and weight Every 6 hours prn allergies, or insect bites Yes/ No Robitussin (guaifenesin) By mouth (syrup) Per label instructions Every 4 hours prn cough Yes/ No Claritin (loratidine) By mouth (tablets) 10 mg Daily prn allergy symptoms Yes/ No Zyrtec (Cetirizine HCl) By mouth (tablets) 10 mg Daily prn allergy symptoms Yes/ No Allegra (fexofenadine) By mouth (tablets) 180 mg Daily prn allergy symptoms Yes/ No Tums (calcium carbonate) By mouth 840 mg Every 2 hours prn acid Yes/ No (chewable tablets) indigestion Lactaid (lactase) By mouth (caplets) Three caplets With first bite of dairy Yes/ No Sunblock or sunscreen Apply topically SPF>30 Apply prn prior to sun Yes/ No exposure Insect repellant Apply topically Aerosol or pump Per label instructions Yes/ No Bacitracin Ointment Apply topically Bacitracin Zinc 500 Apply 1-3x/day daily prn Yes/ No U minor cuts Hydrocortisone cream Apply topically Hydrocortisone 1% Apply 3-4x/day prn skin Yes/ No irritation Antifungal cream Apply topically Tolfnaftate1% Apply twice daily to soothe Yes/ No itching Calamine Lotion Apply topically Per label instructions Apply prn itching Yes/ No Cough drops By mouth (drops) Per label instructions Prn sore throat Yes/ No Arnica Nettle gel Apply topically Per label instructions Apply prn 1 st and 2 nd degree Yes/ No burns, sunburn, insect bites Arnica ointment Apply topically Per label instructions Apply prn sprains, bruises, Yes/ No joint swelling Calendula ointment Apply topically Per label instructions Apply prn to superficial Yes/ No inflammation of the skin Mercurialis Calendula Apply topically Per label instructions Apply prn minor open wounds Yes/ No ointment Traumeel Apply topically Per label instructions Apply prn sprains, bruises, Yes/ No joint pain Rescue Remedy By mouth (tincture) Per label instructions As needed with minor injury Yes/ No It is my opinion that the camper is physically and emotionally fit to participate in an active camp program (except as noted above). Physician/ healthcare provider signature Name of licensed provider: Address : Telephone no.: Date: Parent Signature Date

3 Page 3 Dear Parents, I am writing to inform you about meningococcal disease, a potentially fatal bacterial infection commonly referred to as meningococcal meningitis. New York State Public Health Law (NYS PHL) 2167 and Subpart 7-2 of the State Sanitary Code requires overnight children s camps to distribute information about meningococcal disease and vaccination to all campers who attend camp for 7 or more consecutive nights. Hawthorne Valley Summer Farm Camp Program does not require your child to receive this vaccination in order to attend camp. Hawthorne Valley Summer Farm Camp is required to maintain a record of the following for each camper: A response to receipt of meningococcal disease and vaccine information signed by the camper s parent or guardian; AND EITHER A record of meningococcal meningitis immunization OR An acknowledgement of meningococcal disease risks and refusal of meningococcal meningitis immunization signed by the camper s parent or guardian. Meningitis is rare. Meningococcal disease is a serious bacterial illness. It is a leading cause of bacterial meningitis in children 2 through 18 years old in the United States. Meningitis is an infection of the covering of the brain and the spinal cord. Meningococcal disease also causes blood infections. About 1,000 1,200 people get meningococcal disease each year in the U.S. Even when they are treated with antibiotics, 10-15% of these people die. Of those who live, another 11%-19% lose their arms or legs, have problems with their nervous systems, become deaf, or suffer seizures or strokes. Anyone can get meningococcal disease. But it is most common in infants less than one year of age and people years. Children with certain medical conditions, such as lack of a spleen, have an increased risk of getting meningococcal disease. College freshmen living in dorms are also at increased risk. Meningococcal infections can be treated with drugs such as penicillin. Still, many people who get the disease die from it, and many others are affected for life. This is why preventing the disease through use of meningococcal vaccine is important for people at highest risk. There are two kinds of meningococcal vaccine in the U.S.: Meningococcal conjugate vaccine (MCV4) is the preferred vaccine for people 55 years of age and younger. For example, 2 MCV4 vaccines are Menactra and Menveo. The Centers for Disease Control and Prevention (CDC) recommend two doses of MCV4 for all adolescents 11 through 18 years of age: the first dose at 11 or 12 years of age, with a booster dose at age 16. Adolescents in this age group with HIV infection should get three doses: 2 doses 2 months apart at 11 or 12 years, plus a booster at age 16. If the first dose (or series) is given between 13 and 15 years of age, the booster should be given between 16 and 18. If the first dose (or series) is given after the 16 th birthday, a booster is not needed. Meningococcal polysaccharide vaccine (MPSV4) has been available since the 1970s. It is the only meningococcal vaccine licensed for people older than 55. The trade name of MPSV4 is Menomune. Both vaccines can prevent 4 types of meningococcal disease, including 2 of the 3 types most common in the United States and a type that causes epidemics in Africa. There are other types of meningococcal disease; the vaccines do not protect against these. Information about the availability and cost of the vaccine can be obtained from your health care provider. I encourage you to carefully review the information provided by the National Vaccine Information website at or call (703) in order to make an informed decision about your choices on this issue. To learn more about meningitis and the vaccine, please feel free to contact your child s physician. You can also find information about the disease at the website of the Center for Disease Control and Prevention (CDC): Sincerely, Danielle Fontaine, Camp Director

4 PARENT QUESTIONS/INSURANCE/PERMISSION - To be completed by Parent Page 4 Camper Name: DOB Hawthorne Valley Farm Summer CAMP SESSION (Circle one): HOUSE CAMP: 6/28-7/10, 7/12-7/17, 7/19-7/24, 7/26-8/8, 7/19-8/8 FIELD CAMP: 6/28-7/10, 7/12-7/17, 6/28-7/17, 7/19-8/8 1. Special considerations Does your child have any special considerations such as bed-wetting, sleep-walking, recent medical or psychological treatment, etc.? Please explain. 2. Medical Insurance Information All medical expenses originating from doctor s visits/er visits are the responsibility of the parent/guardian of the camper. Please, provide health insurance information. The medical provider will bill the parent s insurance directly. Include a copy of your insurance card if appropriate; copy both sides of the card. This camper is covered by family medical/hospital insurance yes; no; Insurance Company: Policy No.: Subscriber: Relationship to Participant.: Carrier Address: Insurance Company Phone # 3. Permission for Activity My/Our child has permission to engage in all activities including supervised swimming and incidental immersion (wading through streams) at on/off campus sites during camp unless otherwise noted by the physician or by me. (initials) 4. Permission for Photos I give permission to use photos of my child for camp publicity purposes: yes, no. Parent/guardian with legal custody to be contacted in case of illness or injury: NAME: Relationship to camper: Phone#: Cell #: Additional contact in event parents/guardians cannot be reached: NAME: Relationship to camper: Phone#: Cell #: 5. Permission for Providing Treatment for Emergency Care/Receipt of Meningococcal Information/ Sunscreen Information I hereby authorize Hawthorne Valley Farm to provide routine health care, administer medications as ordered by a physician, obtain emergency medical treatment including radiology and laboratory studies, and arrangement of transportation for same. I agree to the release of any records necessary for medical treatment or insurance purposes. I consent to allow the physician selected by Hawthorne Valley Farm to secure and administer treatment, including hospitalization for the minor named above. (initials) I consent to allow my child to use sunscreen and insect repellent he or she has brought to camp or that is supplied by the camp. He or she may be assisted by unlicensed camp staff to administer the sunscreen or repellent if he or she requests. (initials) This document may be photocopied for off campus trips. (initials) I have read, or had explained to me the information regarding meningococcal meningitis disease, and the availability of vaccine for children greater than 11 years old, as mandated by New York Public Health Law and provided by Hawthorne Valley Farm. My child received the vaccination (initials) OR I wish my child not to receive the vaccination: (initials) Signature of custodial parent/guardian Date

5 CAMPER DIETARY NEEDS FORM (Completed by Parents) Camper Name: Dates of Camp: If Birthday during camp When? Page 5 This information is important for us to know in order to provide the best care and precautions for your child during their stay. Information you provide here will affect our menu plan and let us know if your child has any special needs at the time of the trip that will hinder or prevent them from participating in any activity. Please list only medical issues, not likes or preferences. If there is no issue to inform us of, please indicate that it does not apply so that we know that you read and understand the question. Thank you. Dietary needs: We serve freshly made, vegetarian meals prepared from organic sources, locally grown and produced whenever possible. We are able to accommodate all dietary restrictions, please provide as much detail as possible. Allergen: This item can be served at the table with my child yes no My child can consume this item Raw Cooked In limited quantities Under no circumstances Reaction (please check all that apply) Anaphylaxis Abdominal pain, diarrhea, nausea or vomiting Rash/hives/itching/eczema Swelling of lips, face or tongue Asthmatic/wheezing/nasal congestion Tingling or itching in the mouth Other: (please provide detail) Medication or treatment (Please send this item with your child, clearly marked with their name in the original packaging. FYI: All medicines need to be listed on medical forms by doctor): Allergen: This item can be served at the table with my child yes no My child can consume this item Raw Cooked In limited quantities Under no circumstances Reaction (please check all that apply) Anaphylaxis Abdominal pain, diarrhea, nausea or vomiting Rash/hives/itching/eczema Swelling of lips, face or tongue Asthmatic/wheezing/nasal congestion Tingling or itching in the mouth Other: (please provide detail) _ Medication or treatment (Please send this item with your child, clearly marked in with their name in the original packaging. FYI: All medicines need to be listed on medical forms by doctor): _ (if there are more allergens to report, please make a copy of this form and attach a second or third sheet, remember to complete the top section and number pages 1 of 3, 2 of 3, etc.) (over)

6 Page 6 Environmental Triggers Your child will be working indoors and outdoors in a working farm environment which includes exposure to environmental allergens (pollen, mold, weather conditions, farm animals (cattle, horses, sheep & chickens), animal housing (barns and hay lofts), as well as interior spaces which may mold, dust, etc. Please indicate what your child s trigger is and what treatment is required: Asthma Triggers Treatment (Please send this item with your child, clearly marked with their name in the original packaging, FYI: All medicines need to be listed on medical forms by the doctor) Self-Administered or needs assistance with medication Restrictions to activities if any Insect stings My child is allergic to the following insect stings/bites - Reaction - Medication - (Please send this item with your child, clearly marked with their name in the original packaging. FYI: All medicines need to be listed on medical forms by doctor) My child has never been stung before One or more relative is allergic to stings Recent injury, incident or illness Please let us know if your child has had any issues within the recent past that may require us to alter or eliminate any activity here on the farm. Provide as much detail as necessary. Use a separate sheet if necessary. Has your child had successful overnight experiences with friends away from home? Yes No Does your child have any issue that may hinder their sleeping through the night? Yes No Is there anything else we should know during your child s stay at Hawthorne Valley Farm?

7 Dear Parents/Guardians, Welcome to Hawthorne Valley Farm Camp! It is our pleasure to care for your child this summer. Page 7 The following is a list of required Health Documents that must be received by our office at least three weeks prior to your child s attendance at camp. All Health Exams must be dated within 364 days of the last day of your child s camp session. If we do not receive the health forms prior to the first day of camp, according to NY State Law, your child will not be able to attend camp. These forms are arranged to be printed single or double sided. The first two pages needs to be given to your physician to complete. The rest of the pages are for the parents to complete. To Be Completed by Physician: Pages 1 & 2. Health History, Medications, Immunizations, Over the counter Medicines, Signature of Physician and dated. Be sure that ALL SECTIONS are complete prior to leaving your physician s office. Please review all medications your child takes on a daily basis with your physician, even if they are prescribed by a different physician. (i.e.: gastroenterologist, allergist, etc.), they need to be listed on the health form by the doctor. FYI: All medications sent to camp with your child must be in the original prescription container or packaging. Campers 8 years or older may self-carry only the following medications with written permission from their physician certifying that the minor has been instructed in and is capable in its use, purpose, dosage, administration & effects: Epipen, rescue inhalers, & insulin pumps. Over The Counter Medications include medicines commonly used for fever, aches, pains, bug bites, skin irritation, upset stomach, seasonal allergies, and cold symptoms. Your physician may choose some, or all of the OTC medications available, by circling yes or no on page 2 of the form. Absolutely NO prescription or over the counter medications, supplements, vitamins or topical ointments can be administered without a physician s order, in accordance with New York State Education Law Title 139, section FYI: If you chose not to immunize your child, parents need to provide a Religious Exemption letter along with these forms. All forms must be dated within 364 days of the last day of your child s camp session. To Be Completed by Parents Pages 3 through 7 Page 3. Informational letter on Meningococcal disease and vaccines. FYI: Hawthorne Valley Summer Farm Camp programs do not require campers to receive this vaccination. Page 4. Parent Questionnaire, Medical Insurance Information; Permission to treat in emergency situations and other consent information needed to be initialed by parent. Please provide a copy of your medical insurance card and if applicable pharmacy card. All visits to outside care facilities and new medications purchased during camp will be the responsibility of the parent. Pages 5, 6, 7 Camper Dietary Needs Form and instructions for completing forms Please Fax documents ASAP to (518) or to. We need to receive these documents at least three weeks prior to camp if at all possible. Please retain a copy for your records and bring them on first day of camp in the event any documentation is lost in transmission. Please do not mail forms! For questions, please call Helen at (518) or Danielle at ext.203 We are looking forward to an exciting summer and the opportunity of making Hawthorne Valley Farm Camp a special experience for your children, see you soon, all the best, Helen