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Camper Name: _____________________________________________________________________________
Dates will attend camp: ____________ to _____________ Session Name: ____________________________ Male Female Date of Birth _____/______/_______ 2012 Resident Camp
Health History Form
To Parent(s)/Guardian(s): Please follow the instructions below. Attach additional information if needed. Please return paperwork three weeks prior to
Complete Camp Health History Form (4 pages) and make a copy. start of assigned Session to:
Send the completed original, signed Camp Health History Form by the requested date. FOR RESIDENT CAMPERS ONLY: Complete the top of CAMPER HEALTH EXAM and provide the
copy of Health History with Health Exam Form to your child’s health-care provider for review and completion. After it has been completed and signed by your child’s health-care provider, return Health Exam form & Health History Forms by the requested date. Camper Home Address: _________________________________________________________________________________________________________
Parent/guardian with legal custody to be contacted in case of illness or injury:
camper is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other (Please describe below w hat the camper is allergic to and the reaction seen.)
Name: ________________________________ to Camper: ________________ Preferred Phones: (______) _______________ (______) _______________ Home Address: _______________________________________________________________________________________________________________ (If different from above) Street Address City State Zip Code
Second parent/guardian or other emergency contact:
Name: _________________________________ to Camper: ________________ Preferred Phones: (______) _______________ (______) _____________
Additional contact in event parent(s)/guardian(s) cannot be reached:
Name(s): ______________________________ to Camper: ________________ Preferred Phones: (______) ________________ (______) _______________
Allergies: No known allergies. This camper is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other
(Please describe below what the camper is allergic to and the reaction seen.)
Diet, Nutrition: This camper eats a regular diet. This camper eats a regular vegetarian diet.
This camper has special food needs (Please describe below.)
Restrictions: I have reviewed the program and activities of the camp and feel the camper can participate without restrictions.
I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations. (Please describe below.)
Medical Insurance Information: While at camp, campers and staff are covered under Activity Accident/Sickness Insurance, which will pay the first $100 for covered medical
and dental expenses. After this $100 benefits is paid, further payment will be made, up to the plan maximum, only for covered expenses that exceed the limit of benefits
available under other forms of personal insurance or health care programs. Is the camper covered by family medical/hospital insurance? Yes No If yes, Name of Insurance Company: ________________________________________ Policy Number: ________________________________________________ Insurance Company Phone Number: (____)_______________________________________ Name of Insured: ______________________________________________ Relationship to Camper: __________________________________
Parent/Guardian Authorization for Health Care: This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person
described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status. Parent/Guardian __________________________________________________________________ If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance. Name of Camper: _________________________________________________________ Resident Camp Health History Form Continued Please Return: three weeks prior to start of assigned session
Session Name: ________________________________________ Immunization History: Provide the mo
nth and year for each immunization. Starred ( ) immunizations must be current. Copies of immunization forms from health-care providers or state or local government are acceptable; please attach to this form. Immunization
Most Recent Dose
(DTaP) or (TdaP)
(dT) or (TdaP)
influenzae type B (HIB)
Varicella (chicken pox)
Had chicken pox
If your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being fully immunized.
Parent/Guardian: ______________________________________________________________ Date: _____________ to Camper: __________________________ Medication: This camper will not take any daily medications while attending camp. This camper will take the following daily medication(s) while at camp:
"Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Please review camp instructions about
required packaging/containers. Many states require original pharmacy containers with labels which show the camper’s name and how the medication should be
g iven. Provide enough of each medication to last the entire time the camper will be at camp.
Name of medication
Reason for taking it
When it is given
Amount or dose given
How it is given
If anything has changed since this form was sent it please change and sign and date here: ______________________________________________ The following non-prescription medications in brand name or generic may be stocked in the camp Health Center and are used on an as needed basis to
manage illness and injury. Cross out those the camper should not be given.
Diphenhydramine antihistamine/allergy medicine (Benadryl) Dextromethorphan cough syrup (Robitussin DM) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Name of Camper: ___________________________________________________________ Resident Camp Health History Form Continued Please Return: three weeks prior to start of assigned session
Session Name: ________________________________________ Unit: ______________ General Health History: Check "Yes" or "No" for each statement. Explain “Yes” answers below.
1. Ever been hospitalized?…………………………. 12. Passed out/had chest pain during exercise? ….…………… . Have recurrent/chronic illnesses? .……….… 13. Had mononucleosis ("mono") during the past 12 months?. 4. Had a recent infectious disease? . …………. . 14. If female, have problems with periods/menstruation?.………. . Had a recent injury? . …………. . 15. Have problems with falling asleep/sleepwalking? . . 6. Had asthma/wheezing/shortness of breath?. … 16. Ever had back/joint problems?…….……….……………. 17. Have a history of bedwetting?………………….……………. 18. Have problems with diarrhea/constipation?………………. Had headaches? ……………………………………… 19. Have any skin problems?……………………. 10. Wear glasses, contacts, or protective eyewear?. 20. Traveled outside the country in the past 9 months?.
Pl ease explain “Yes” answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited and dates of travel.
M ental, Emotional, and Social Health: Check "Yes" or "No" for each statement.
Has the camper: 1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)? ………………………. . 2. Ever been treated for emotional or behavioral difficulties or an eating disorder?……. 3. During the past 12 months, seen a professional to address mental/emotional health concerns?……….……………………………………………… 4. Had a significant life event that continues to affect the camper’s life?. (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others)
Pl ease explain “Yes” answers in the space below, noting the number of the questions. The camp may contact you for additional information.
N ame of camper’s primary doctor(s): ____________________________________________________
Phone: (________) __________________________ ame of dentist(s):___________________________________________________________________ Phone: (________) __________________________ Name of orthodontist(s):_______________________________________________________________ Phone: (________) __________________________ What Have We Forgotten to Ask? Please provide in the space below any additional information about the camper’s health that you think important or that may affect the
amper’s ability to fully participate in the camp program. Attach additional information if needed.
To Parent(s)/Guardian(s): Complete this section and give this form (FORM 2) and a copy of
your completed CAMPER HEALTH HISTORY FORM (FORM 1) to your child’s health-care
Dates will attend camp: from ______________to_____________ Session: ______________________________ Camper Name: ______________________________________________________________________________ 2012 Resident Camp
Health Exam Form
Please return paperwork three weeks prior to
Camper home address: _______________________________________________________________________ start of assigned Session to:
___________________________________________________________________________________________ Custodial parent(s)/guardian(s) phone: (_______) ______________ (_______) ____________ Parent(s)/guardian(s) stop here. Rest of form to be completed by medical personnel.
The following non-prescription medications are Medical Personnel: Please review the CAMPER HEALTH HISTORY FORM and complete all remaining
commonly stocked in camp Health Centers and are sections of this form. Attach additional information if needed.
used on an as needed basis to manage illness and injury. Medical personnel: Cross out those items
the camper should not be given.
Physical exam done today: Yes No (If “No,” date of last physical: (___________)
*ACA accreditation standards specify physical exam within last 24 months.
Pseudoephedrine (Sudafed) Chlorpheneramine maleate Dextromethorphan Diphenhydramine (Benadryl) Allergies: No Known Allergies
To foods (list):
Lice shampoo or scabies cream (Nix or Elimite)
To medications: (list):
To the environment (insect stings, hay fever, etc.– list):
Other allergies: (list):
Describe previous reactions:
Diet, Nutrition: Eats a regular diet. Has a medically prescribed meal plan or dietary restrictions: (describe below)
The camper is undergoing treatment at this time for the following conditions: (describe below)
Medication: No daily medications.
Will take the following prescribed medication(s) while at camp: (name, dose, frequency—describe below)
Other treatments/therapies to be continued at camp: (describe below)
Do you feel that the camper will require limitations or restrictions to activity while at camp? No Yes
“I have reviewed the CAMPER HEALTH HISTORY FORM (FORM 1), and have discussed the camp program with the camper’s parent(s)/guardian(s). It is my opinion that the
camper is physically and emotionally fit to participate in an active camp program (except as noted above.)
Name of licensed provider (please print): _________________________________________________________
Signature: ________________________________________ Title: _______________________________________ Telephone: (________) _____________________________ Office Address_________________________________________________________________________________________________________________________________ Street If you answered “Yes” to the question above, what do you recommend? (Describe below or attach additional information if needed)
Name of Camper: _______________________________________________________________________
Session Name: __________________________________________________________________________
As a legal guardian I give permission for the registrant to participate in all phases of camp activities and off-site trips. I understand and agree to
cooperate with all regulations. I will not allow registrant to attend if not in good physical condition. In an emergency, when the undersigned or other
person named cannot be reached, I give permission for the camp authorities to take any emergency measures deemed appropriate. It is understood that
all reasonable efforts will be made to contact the parent/guardian. I understand that when participating in Girl Scout activities the registrant may be
photographed for print, video or electronic imaging. I understand that the images may be used in promotional and fundraising materials, news releases
and other published formats, and will be the sole property of Girl Scouts of South Carolina – Mountains to Midlands, Inc. its assigns or successors, or
Girl Scouts of the USA.
Check if registrant :
MAY NOT: □ Be photographed for Girl Scout publicity purposes
MAY NOT: □ Participate in _____________________________________ e.g., active sports, swimming, etc
Parent/Guardian Signature: _________________________________________________
MAY NOT: □ Participate in _____________________________________
Horseback Riding Permission
Only girls registered for sessions that include horseback riding and who have a signed permission form will be allowed to ride.
Parent/Guardian Signature: _________________________________________________ We give permission for our daughter _________________________________ to participate in the horseback-riding program provided by Girl Scouts of South Carolina - Mountains to Midlands which carries Girl Scout Accident and Sickness Insurance with Mutual of Omaha on each girl. ease Note: Each girl is required to have gloves, long pants, and shoes or boots with a ½” heel and smooth soles when she rides.
CAMPER CODE OF CONDUCT
I understand that my attitude and behavior are critical to the success of this summer camp experience. Therefore, for the good of this program, as well as my fellow group members, I agree to abide by the following: I will respect the places and people with whom I come in contact. I will keep my hands, feet, mouth, etc. to myself and not use them against another camper or counselor. I will be respectful to my fellow campers and counselors with my words and actions. I will be sensitive to the needs of each person by performing my assigned duties. I will be responsible for my personal belongings and equipment. I will follow all rules and regulations of the camp and counselors. I will use any safety equipment furnished for my own safety. I will observe safety precautions for all activities within the program. Such observations will include use of a buddy system, checking in and out with staff and taking all other safety precautions that will be discussed with participants. I understand that often the activities will be physical and mentally demanding, but these demands will be to the benefit of me as well as the I understand that the use of alcohol and illegal drugs or misuse of prescription drugs will not be tolerated, and that such usage during the program will result in expulsion from camp. I understand that cell phones and other electronics are prohibited from camp and can be confiscated by the camp director at anytime and held until returned to my parent/guardian the end of the week. I understand that if I am sent home early due to any misconduct as outlined above, it will be at my parent’s/guardian’s expense. Disciplinary Actions:
2) Written reprimand to be signed by camper and a phone call to parent/guardian by Camp Director 3) Parent/guardian will be called and camper will be removed from camp Code of Conduct Agreement:
After reading the Code of Conduct, I understand and agree that any violation may result in my immediate departure from camp. My parent/guardian will be notified and all arrangements for my return home will be my family’s expense with no refund of camp payment. Participant Signature________________________________________________ Date ___________________________ I have read and understand the Code of Conduct and agree to abide by its stipulations for my child. Parent/Guardian Signature ___________________________________________ Date ___________________________
I. Médico: Registro de Especialidades no CRM-PR: Clínica Médica e Nefrologia II. Cursos de Línguas Estrangeiras: - Nível de Proficiência em Língua Inglesa exigido pela Fundação Richard III. Formação Acadêmica Médica: - Graduação em Medicina pela Universidade Federal do Rio Grande do - Residência Médica em Clínica Médica no Hospital Universitário Onofre - Resi