DAY CAMP MEDICAL INFORMATION

A completed health form must be on file for every person attending Day Camp. The Council Accident and Sickness Insurance Plan, covers all youth and adults registered with the Boy Scouts of America.  Any medication is to be taken before camp or during camp; a Physician’s signature is required.

NAME:                                                         Age:             Weight:                 DOB:                   

Address:                                                                                                                                  

Home #                                      Cell #                                       WK#                                      

IN CASE OF EMERGENCY NOTIFY:

Name:                                                  Relation:                                   Phone:                           

Name:                                                  Relation:                                   Phone:                           

 

HEALTH HISTORY

Check all items that apply, PAST or PRESENT, to your health history.  Please explain all checked items

             Sports Restrictions                                     ADHD/ADD**                                  ASTHMA**

             Allergies**                                                    Diabetes                                             Heart Trouble

             Convulsions                                                    Fainting Spells                                   Digestion

             Hemophilia                                        Migraines                              Eyes/Ears/nose/throat treatment

**Asthma and allergies require completion of the additional information on the form.

**ADHD/ADD that requires medication during the week of Day Camp must be given to the nurse on the First Day of camp.

Explanation of restrictions, medical conditions, etc:                                                                                                                                                                                                                                                                              

Medication taken on a regular basis, include dosage:                                                                                                                                                                                                                                                                             

What medication will need to be taken during camp?                                                                                                                                                                                                                                                                             

TREATMENT AUTHORIZATION

Health history is correct so far as I know, and the person herein described has my permission to engage in all activities except as noted by the physician or myself.  In the event I cannot be reached in an emergency, I hereby give permission to the Day Camp Directors to hospitalize, secure proper anesthesia or to deliver such care as medically appropriated to the injury or illness.

Signed:                                                                                                             (parent or guardian if under 18)

Printed Name:                                                                                        Date:                                                  

 

PHYSICIAN’S SIGNATURE (Required for anyone taking medication, at camp or before camp or for any condition limiting activity)

M.D. Signature:                                                       Phone:                             Date:                   

Address:                                                                                                                                  

 

ALLERGY and ASTHMA INFORMATION:  ALL EPI PENS AND INHALERS SHOULD BE NOTED FOR DEN LEADER, CAMPDIRECTOR AND PROGRAM DIRECTOR.  IF ANYPLEASE LET US KNOW IF YOU’RE NOT SURE IF THEY HAVE ANY ALLERGIES THAT ARE BEING TESTED FOR.

 

Allergy Type:                                                               

Reaction:         Mild       Moderate       Severe

Medication require to control reaction (if any):                                                                                                

Prescription for above medication?                              

Medication with nurse at camp?                                   

Prescription for EPI Pen or Inhaler?                            

EPI PEN or INHALER with child at all times?               

                                                                                   

Allergy Type:                                                               

Reaction:        Mild        Moderate         Severe

Medication required to control reaction (if any):          

                                                                                   

Prescription for above medication?                              

Medication with nurse at camp?