Camp Judah Health Form - Health Provider

Camp Judah Health Form - Medical Provider
Camp Located at: 2970 Kohler Rd. Varysburg, NY 14167 (585)535-7832
Dear Medical Provider,

Your patient is applying to attend a week of summer camp. There will be a nurse at camp during the week to provide for any health care needs. Your office and the camper’s parents may be contacted should a health situation warrant. There is a local hospital approximately 15 miles away where emergency services are available.

Please review the following general prn orders. If you would like to adjust a medication or dosing, you may add your comments in the note section of the order. Your signature at the end of this form will authorize the camp health personnel to administer treatment should your patient require it during their week at camp. (Camp health personnel meet all license and certification standards according to the New York State Sanitary Code for Overnight Camps.)
Patient's Full Name
Patient's DOB

MonthDayYear
Date
Standing Orders for Camp Health Care
Seasonal Allergy Symptoms: Benadryl, Loratadine, Cetirizine, or Fexofenadine per dosing instruction.
Mild Pain: Tylenol or Ibuprofen per dosing instruction.
Bee Sting WITH anaphylactic reaction (or ANY ANAPHYLACTIC REACTION): Give Epi-pen and call 911 immediately.
Contact Dermatitis/Skin Allergies: Apply hydrocortisone cream per dosing instruction.
Stomach upset: Assess for dehydration, give clear liquids. Tums may be given for acid indigestion.
Persistent Cough: Mucinex per dosing instruction.
ADDITIONAL PRN MEDICATIONS THAT MAY BE GIVEN
Current Known Allergies
Medications
Food
Insect stings
Other
List any food or activity restrictions

Please list ALL medications (including over the counter or nonprescription drugs) taken regularly.

Rows	Medication	Dosage	Specific times taken each day	Purpose
1
2
3
4

Please fax or email a current immunization record and any additional medication instructions. (contact info at end of this form)
Camper may keep inhaler with him at all times. (Please check if applies)
Date of last physical exam (does not need a physical to attend camp)

MonthDayYear
Date
Additional information pertinent to this registrant:
In my opinion, the above registrant is able to participate in an active camp program.
X
*Signature of Licensed Medical Personnel (MD, PA, or NP ONLY)

*This signature is REQUIRED for any and every camper or for any staff member under the age of 19. By signing this form, the MD, PA or NP is indicating they have read the entire health form. An electronic signature is acceptable. If you prefer to fill out a paper copy to sign, click here: Camp Judah Health Care Form - Medical Provider
Today’s Date

MonthDayYear
Date
Printed Name of Physician
Phone
Professional Lic. Number
Provider's Full Address
This form must be fully & accurately completed and submitted prior to the onset of camp.

Admin. Address: CAMP JUDAH 2444 N Main St., Warsaw, NY 14569

Email: campjudah@gmail.com

Regular Fax (except during week of camp): 585-786-8249

Fax during week of camp only: (June 29 – July 5, 2024): 585-687-4624
Should be Empty:

Camp Judah Health Form - Medical Provider

Standing Orders for Camp Health Care

Current Known Allergies