Health History and Emergency Care Form
Use of form: This form is voluntary and meets the requirements in DCF 250.04(6)(a)1., DCF 251.04(6)(a)6., and DCF 252.41(4)(a)6. of the Wisconsin Administrative Codes. Failure to comply may result in issuance of a noncompliance statement. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes].
Instructions: The parent / guardian may complete this form for placement in the child’s file prior to the child’s first day of attendance. Information contained on the form shall be shared with any person caring for the child. The department recommends that parents / guardians and center staff periodically review and update the information provided on this form.
Child information
Child's Name (First, Last, MI)
*
First Name
Last Name, MI
Child's Birth Date
*
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Month
-
Day
Year
Date
Which Week(s) of Camp is Your Child Attending? Please double check your registration confirmation email for the correct weeks.
*
Critters Club (Week 1, 4-6 year olds)
Trail Trekkers (Week 1, 7-11 year olds)
Nature Detectives (Week 2, 4-6 year olds)
Boreal Pioneers (Week 2, 7-11 year olds)
Happy Hikers (Week 3, 4-6 Year olds)
Mucky Ducks (Week 3, 7-11 year olds)
Tiny Twigs (Week 4, 4-6 year olds)
Ridges Rangers (Week 4, 7-11 year olds)
Climbing Caterpillars (Week 5, 4-6 year olds)
Mighty Monarchs (Week 5, 7-11 year olds)
Bug Me (Week 6, 4-6 year olds)
6-Legged Science (Week 6, 7-11 year olds)
First Day of Attendance
*
-
Month
-
Day
Year
Date
Child's Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent / Guardian Information
Provide information where the parent(s) / guardian(s) may be reached while the child is in care.
Parent / Guardian 1: Name
*
First Name
Last Name
Primary Phone Number
*
Please enter a valid phone number.
Secondary / Work Phone Number
*
Please enter a valid phone number.
Parent Guardian 2: Name
*
First Name
Last Name
Primary Phone Number
*
Please enter a valid phone number.
Secondary / Work Phone Number
*
Please enter a valid phone number.
Physician / Medical Facility Information
Please fill this out completely on both the Enrollment Form and this form.
Physician Name
*
First Name
Last Name
Medical Facility Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Facility Phone Number
*
Please enter a valid phone number.
Health History and Emergency Care Plan
If available, send any health care plan information from the child’s physician, therapist, etc. to ana@ridgessanctuary.org with your child's name and the week of camp they are attending in the email body.
Check any special medical condition your child may have
*
Any disorder, including Cognitively Disabled, LD, ADD, ADHD, or Autism
Asthma
Cerebral Palsy / motor disorder
Diabetes
Epilepsy / seizure disorder
Gastrointestinal/ feeding concerns, including special diet and supplements
Other conditions requiring medical care (specify below)
No specific medical condition
Other conditions:
Check any allergies your child may have
Food Allergy
Milk Allergy
Other Food Allergy - Specify Below
Non Food allergy - Specify Below
If you checked one of the above boxes for allergies, please specify below.
Please specify triggers that may cause problems for medical conditions and/or allergies:
Please specify signs and symptoms to watch for (medical conditions and/or allergies):
In the event of symptom, identify the steps the counselor should follow. If prescription or non-prescription medications are necessary, a copy of the form Authorization to Administer Medication should be submitted. (In general, medications will not be administered by Ridges staff. Staff will utilize EpiPen or asthma inhaler if indicated on this form. Contact Ana Hinkle if medication is required: (920)-839-2802 ext. 105).
Identify any child care staff to whom you have given specialized training / instructions to help treat symptoms:
When to call parents regarding symptoms or failure to respond to treatment:
When to consider that the condition requires emergency medical care or reassessment:
Additional information that may be helpful to the childcare provider:
*
Please note: if your child uses an EpiPen or Inhaler, please fill out the Medication Authorization Form and carry a copy with your child's inhaler and/or EpiPen.
Signature of Parent/Guardian
Please make sure you have filled out this form completely and that all information is correct.
Type Name Below
*
First Name
Last Name
Date Signed:
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: