SLEEPAWAY CAMPER HEALTH FORM 2022

CAMPER HEALTH FORM 1

Developed and reviewed by: American Camp Association, American Academy of Pediatric Council on School Health, & Association of Camp Nurses
Camper Name*

First NameLast Name
Camper Home Address:*

Address

Street Address Line 2

CityState

Postal / Zip Code
Camper Zip Code:*
Camper Birth Date:*

MonthDayYear
MaleFemale
Camper Race:*
Hispanic or LatinoNot Hispanic or Latino
Camper Grade as of April 2022:*
Camper Grade as of September 2022:*
Camper School as of April 2022:*
Camper School as of September 2022:*
YESNO
Camper Home Language:*
Parent/Guardian with legal custody to be contacted in case of illness or injury: *

First NameLast Name
Relationship to Camper*
Home Address (if diffferent than above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Phone Number:*
Parent/Guardian Email:*
example@example.com
Second Parent/Guardian or other emergency contact: *

First NameLast Name
Relationship to Camper:*
Second Parent/Guardian or other emergency contact phone number:*
Please enter a valid phone number.
Second Parent/Guardian or other emergency contact email:*
example@example.com
Date camper starts overnight camp:*
Which camp is your child attending?*
Based on the camp your child is attending, what is your child's skill level?*
Please be honest! Being in the wrong skill level will not improve the camp experience.
Who will drop off the camper on Monday?*
Name: If not the parent/guardian filling out this form, please also provide phone number and relation of person dropping off.
Who will pick up the camper on Thursday?*
Name: If not the parent/guardian filling out this form, please also provide phone number and relation of person picking up. They must show ID when picking up.
YESNO
YESNO
YESNO
If the camper is not sleeping at Camp Grace, what time will you pick them up each evening?
(Must be between 5:45-8:45PM) (Dinner is at approximately 5:45 each evening)
This camper eats a regular diet.This camper eats a regular vegetarian diet.This camper is lactose intolerant.This camper is gluten intolerant.Other, please explain in space.
Diet, Nutrition Details:
Please describe camper's diet/nutrition restrictions.
No known allergies.This camper is allergic to a FoodThis camper is allergic to a MedicineThis Camper is allergic to the environment, insect stings, hay fever, etc
Allergies: Please describe below what the camper is allergic to and the reaction seen:
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
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:
Please provide details on what restrictions the camper may have
Hiking Mt Baldy (approximately 4 hours)Tubing at Sunrise Park ResortHorseback RidingNo preference
CAMPER HEALTH FORM 2

Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses
Camper Name:*

First NameLast Name
Camper Birth Date:*

MonthDayYear
Date
Immunization History:

Rows	Dose 1	Dose 2	Dose 3	Dose 4	Dose 5
Diptheria, tetanus, pertussis (DTaP) or (TdaP)
Polio (IPV)
Haemophilus Influenza Type B (HIB)
Pneumococcal (PCV)
Hepatitis B
Hepatitis A
Varicella (chicken pox)
Meningococcal Meningitis (MCV4)

Tetanus Booster
Most recent dose:*

MonthDayYear
Date
PositiveNegative
Date of Tuberculosis Test:

MonthDayYear
Date
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.
Signature*
Parent/Guardian Name:*

First NameLast Name
Relationship to Camper:*
Date:*

MonthDayYear
Date
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.Original pharmacy containers with labels which show the camper's name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp.

Rows	Name of Medication	Date Started	Reason for taking it	When it is given	Amount or dose given	How it is given
1.
2.
3.
4.

Signature*
Parent/Guardian Name:*

First NameLast Name
Relationship to Camper:*
Date*

MonthDayYear
Date
The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Select those the camper should NOT be given.
Acetaminophen (Tylenol)Phenylephrine decongestant (Sudafed PE)Anthistamine/allergy medicine DiphenhydramineAnthistamine/allergy medicine (Benadry Sore throat spray)Lice shampoo or cream (Nix or Elimite)Calamine lotionLaxatives for constipation (Ex-Lax)Ibuprofen (Advil, Motrin)Pseudoephedrine decongestant (Sudafed)Gualfenesin cough syrup (Robitussin)Dextromethorphan cough syrup (Robitussin DM)Generic cough dropsAntibiotic creamBismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol)Aloe"At home" Covid Swab Test
Signature*
Parent/Guardian Name:*

First NameLast Name
Relationship to Camper:*
Date*

MonthDayYear
Date
CAMPER HEALTH FORM 3

Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses
Camper Full Name*
First Middle Last
Birth Date*

MonthDayYear
Date

General Health History: Check "Yes" or "No" for each statement. Explain "Yes" answers below.*

Rows	YES	NO
Ever been hospitalized?
Ever had surgery?
Have recurrent/chronic illnesses?
Had a recent infectious disease?
Had a recent injury?
Had asthma/wheezing/shortness of breath?
Have diabetes?
Had seizures?
Had headaches?
Wear glasses, contacts, or protective eyewear?
Had fainting or dizziness?
Passed out/had chest pain during exercise?
Had mononucleosis ("mono") during the last 12 months?
If female, have problems with periods/menstruation?
Have problems with falling asleep/sleepwalking?
Ever had back/joint problems?
Have a history of bedwetting?
Have problems with diarrhea/constipation?
Have any skin problems?
Traveled outside the country in the past 12 months?
Is a foster child?

Please explain "Yes" answers in the space below, noting the number of the questions. The camp may contact you for additional information.

Mental, Emotional, and Social Health: Check "Yes" or "No" for each statement.*

Rows	YES	NO
Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?
Ever been treated for emotional or behavioral difficulties or an eating disorder?
During the past 12 months, seen a professional to address mental/emotional health concerns?
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)

Please explain "Yes" answers in the space below, noting the number of the questions. The camp may contact you for additional information.
Name of camper's primary doctor(s):*
Primary doctor's phone number:*
Name of Orthodontist:
Orthodontist's phone number:
Please enter a valid phone number.
Name of Dentist:
Dentist's phone number:
Please enter a valid phone number.
YesNo
Insurance Company
Policy Number
Insurance Company Phone Number
Signature*
Parent/Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date
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.
Signature of Custodial Parent/Guardian*
Parent/Guardian Name:*

First NameLast Name
Date*

MonthDayYear
Date
Relationship to camper:*
Should be Empty:

CAMPER HEALTH FORM 1

CAMPER HEALTH FORM 2

Tetanus Booster

CAMPER HEALTH FORM 3