Benton Day Camp -- Camper Health History & OTC Medications

Name:* This field is required.

First Name

Last Name

Birthdate* This field is required.

Date

Sex* This field is required.

Current Age* This field is required.

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Parent/Guardian Name(s)* This field is required.

Primary Phone* This field is required.

Example: ###-###-####

Secondary Phone

Example: ###-###-####

Email* This field is required.

example@example.com

Family Medical / Hospital Insurance Carrier* This field is required.

Policy or Group #* This field is required.

Emergency Contact #1* This field is required.

First Name

Last Name

Relationship to Camper* This field is required.Emergency Contact #1

Daytime Phone* This field is required.Emergency Contact #1

Evening Phone* This field is required.Emergency Contact #1

Emergency Contact #2* This field is required.

First Name

Last Name

Relationship to Camper* This field is required.Emergency Contact #2

Daytime Phone* This field is required.Emergency Contact #2

Evening Phone* This field is required.Emergency Contact #2

Chronic or Recurring Illnesses

Heart Defect / Disease

Seizures

Bleeding / Clotting

Asthma

Diabetes

Other

Explain any checked boxesfor Chronic or Recurring Illnesses

Any restrictions concerning physical activities?* This field is required.

Yes

Please describe any conditionsregarding restrictions concerning physical activities

Allergies

Food, Nuts

Insect Stings

Medicine / Drugs

Other

Explain any checked boxesregarding Allergies

Special Dietary Restrictions?

Tetanus -- Date of shot or last booster (year)* This field is required.

Year

Please list any medications taken on a daily basis, including over-the-counter medications.

Please list any conditions we should be aware of (cognitive, developmental, emotional or behavioral) to make camp a more positive experience for your camper.

Any other relevant health concerns

According to our Day Camp Protocols and Health Care Procedures, our health care staff can administer certain types of over-the-counter (OTC) medications. In order for your camper to be able to receive these, we need to have a parent/guardian signature.

Check box if camper MAY RECEIVE any of the following OTC medications:Unchecked boxes means camper MAY NOT receive that medication

Acetaminophen (Tylenol or generic)

Ibuprofen (Advil or generic)

Diphenhydramine (Benedryl or generic)

Non-medicated cough drops

Insect repellent (may contain up to 15% DEET)

OTC Antacid (Tums)

Calamine lotion

Antibiotic ointment

Sunscreen (without PABA, minimum SPF 30)

Hydrocortisone

Weight of child for dosage purposes* This field is required.

If there are any medications brought from home that your camper may need at camp, please provide these in original packaging with doctor/parent instructions at the start of camp.

List medications

Instructions for administration

The camper below has my permission to receive the above mentioned over-the-counter and/or prescription medications.Camper's Name

First Name

Last Name

Parent / Guardian Signaturefor camper's over-the-counter and/or prescription medications

Clear

Parent/Guardian Printed Signaturefor camper's over-the-counter and/or prescription medications

First Name

Last Name

Date

CAMPER

By entering my name below, I/We verify that this health history is complete and accurate. My child has permission to engage in all prescribed activities, except as noted by me. In case of illness or injury, I/we give permission for her/him to receive first aid and to receive emergency treatment from a licensed physician, emergency medical services or other health care professional. It is understood that all reasonable efforts will be made to contact the parent or guardian. I/We verify my child has my permission to receive the above-mentioned over-the-counter medications.

ADULT

By entering my name below, I verify that this health history is complete and accurate. I am able to engage in all prescribed activities, except as noted.

Parent/Guardian Signature* This field is required.

Clear

Parent/Guardian Printed Signature* This field is required.Printed Name

First Name

Last Name

Today's Date* This field is required.for Electronic Signature

Date

Benton Day Camp -- Camper Health History & OTC Medications