Mt. Hood Kiwanis Camp Health History and Examination Form
Please give complete information below so the camp is aware of your camper’s needs and has the information necessary for appropriate care. If there are changes after you send us the form, please notify the nurse upon arrival at camp. Camper Last Name __________________________________ First _________________Nickname_________________
Birth date ______________________________ Age at camp _________________Social Security #_______________________[ ] Male [ ] Female Custodial parent/guardian _________________________________________________________________________________________________ Home address _____________________________________________ City, State, Zip______________________________________ Home phone_____________________________ Business address __________________________________________ City, State, Zip ______________________________________ Business phone _________________________ Second parent/guardian or emergency contact ________________________________________________________________________________ Home address _____________________________________________ City, State, Zip______________________________________ Home phone____________________________ Business address __________________________________________ City, State, Zip ______________________________________ Business phone _________________________ Group home name ______________________________ Manager _________________________________ Phone _________________________ If above persons are not available in an emergency, notify:
Ful name______________________________________ Relationship to camper _____________________ Business phone __________________ Address _______________________________________________________________________________ Home phone _________________________ Family Physician_________________________________________________________________________ Phone _________________________ Dentist/Orthodontist ______________________________________________________________________ Phone _________________________ Is the camper covered by medical/hospital insurance? [ ] Yes [ ] No If yes, give carrier or plan name ________________________________________________________Policy/Group # ________________________ Name of insured/relationship to camper __________________________________________________Insurance ID # _______________________ AN IMPORTANT MESSAGE REGARDING MEDICATION WHILE AT CAMP

Dear Parents/Caregivers-
This letter is designed to give you information regarding the administration of medication at Mt. Hood Kiwanis Camp. A
registered nurse wil administer al medications at Camp. During check-in YOU MUST WAIT IN LINE AND GIVE
. During this check-in you wil be able to discuss any medical questions you may
have and to give any special instructions about the administration of medicine to your camper. An individual medical log
sheet wil be completed for any medication provided. You wil be asked to review and initial this log sheet with the nurse.
The fol owing guidelines have been established to ensure the safe and proper administration of medicine.

1. Each medication, including over-the counter medication and vitamins must be in its original container with the
proper label.
2. For prescription medications, the prescription must be current (within 1 year), in the camper’s name and with the
proper instructions.
If the instructions/dosages have changed, you must provide a doctor’s note stating the new
3. Please send extra pil s/liquid medication in the event that medication is dropped or spit out and becomes unfit for
4. If your camper needs special equipment (e.g. a certain cup or straw) or food other than applesauce (e.g. pudding or
yogurt) to take medication, please bring these to camp in the original container, labeled with camper’s name.

In addition to the medications you provide for your camper, Camp nurses have standing orders to administer certain over-
the-counter-medications. These medications are listed on page 5 for your review. There are two options that you may
choose from. You may change this choice at any time.
Please complete ONE of the two options. In most cases the nurse wil not cal when these medications are given. However,
you would be notified right away if your camper is seriously il or does not respond to over the counter medication. The
administration of these medications is documented in the Camp treatment log. Complete option 2 on the reverse side if you
would like to be notified prior to the administration of these medications. Please note that this option may cause a delay in
your camper’s symptoms if you are not readily available.
This Box Must be Complete for Attendance
Parent/Guardian Authorizations: This health history on both pages is correct and complete to the best of my knowledge.
The person herein described has permission to engage in al camp activities except as noted.
I hereby give permission to the camp to provide routine health care, administer prescribed medications and seek emergency
medical treatment including ordering x-rays or routine tests. I agree to the release of any record necessary for insurance
purposes. I give permission to the camp to arrange necessary related transportation for this participant. In the event I cannot
be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer
treatment, including hospitalization, for the participant. I also agree to be responsible for any expenses which may be
incurred in providing emergency medical or surgical treatment to this participant. This completed form may be photocopied
for trips out of camp.
Signature of parent/guardian or adult camper_________________________________________________________
Printed name _______________________________________________________________________
Date _____________________________
Camper’s Name: _____________________________________________

1 Recent injury, il ness or infectious disease? 9 Ever passed out during or after exercise? 20 Had mononucleosis in the past 12 months? 10 Ever been dizzy during or after exercise? 21 If female, abnormal menstrual history? 11 Ever had chest pain during or after exercise? Please explain any ‘yes’ answers, noting the number of the questions: ______________________________________________________________ ______________________________________________________________________________________________________________________Attach additional pages if necessary
Allergies: List al known al ergies. Describe reaction and management of the reaction. Attach additional page if necessary.
Medication al ergies:______________________________________________________________________________________________________
Other al ergies (include insect stings, hay fever, asthma, animal dander, etc.:_________________________________________________________
Food al ergies: __________________________________________________________________________________________________________
Wil this camper need a special diet? If so, please provide al necessary food for this camper for the week. IE Gluten and Casein free diets

Medications Being Taken: List ALL medications including over-the-counter or non-prescription drugs taken routinely. Bring enough to last the
entire time at camp. Keep it in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage and the frequency of administration. This list wil aid the health care staff at camp, so while we realize that these might
[ ] This person takes NO medications on a routine basis.

Name of Prescription
Time Given

Name of PRN (as needed)
Reason for Medication

Name of Vitamin/Supplement

Camper’s Name: _____________________________________________
please attach sheet if necessary
Please give al dates of immunizations (write 'none' if not immunized): Date of last TB Mantoux Test_______________ __________________________________________________________________________
To Be Completed by Licensed Health Care Provider
I have examined the above-named camp participant within two years prior to camp attendance. Date examined:______________
In my opinion, the above applicant [ ] is [ ] is not able to participate in an active camp program. Height __________ Weight __________ Blood Pressure _____________ Diagnoses _________________________________________________ The participant is under the care of a physician for the fol owing conditions: __________________________________________________________ ______________________________________________________________________________________________________________________ Recommendations and Restrictions while at Mt. Hood Kiwanis Camp Treatment to be continued at camp _________________________________________________________________________________________ ______________________________________________________________________________________________________________________ Medications to be administered at camp (name, dosage, frequency) _______________________________________________________________ ______________________________________________________________________________________________________________________ Any medical y prescribed dietary restrictions __________________________________________________________________________________ ______________________________________________________________________________________________________________________ Known al ergies _________________________________________________________________________________________________________ Describe any limitation or restriction on camp activities __________________________________________________________________________ Does this person have a positive diagnostic x-ray for Atlantoaxial Dislocation Condition? ____ If yes, give activity restrictions relating to horseback riding adventure course, etc. ______________________________________________________________________________________________ Please attach additional information that may assist health care staff at camp.
Signature of Health Care Provider ______________________________________________________ Date _______________________
Printed Name ______________________________________________________________________ Phone ______________________________ Address _______________________________________________________________________________________________________________ Please send to Mt. Hood Kiwanis Camp Office, 9320 SW Barbur Blvd. Suite 165, Portland OR 97219-5430

Camper’s Name: _____________________________________________
Camp Physician Standing Orders
At times, it maybe become necessary to treat minor ailments from our Camp Physician Standing orders. The
following medications may be used. Please indicate whether these medications are acceptable to give your
camper under the direction of the Mt. Hood Kiwanis Camp Standing Orders.
Benadryl or Generic Equivalent (for allergic reactions and sleep) Glycerin or Dulcolax suppository (for constipation) Epinephrine (for serious allergic reaction) Ematrol or Generic Equivalent (for nausea) Midol or Generic Equivalent (for menstrual cramps) Ivy Dry/Ivy Stat or Generic Equivalent (for poison oak) Pepto Bismo (for upset stomach, nausea, or diarrhea) Swimmer’s Ear or Generic Equivalent- water drying drops
I authorize the Mt. Hood Kiwanis Camp to administer the medications listed on the Camper Medication Record
page according to the manufacturers’ written instructions. The medication information given today supersedes
any previous information given at the time of registration.
I authorize the Mt. Hood Kiwanis Camp to administer any of the above medications indicated “yes” according
to the Camp Standing Orders, as necessary for minor ailments.
Parent/Guardian/Camper Signature: ___________________________ Date:____________

Camper’s Name: _____________________________________________

Please read and sign this page

Mt. Hood Kiwanis Camp, Inc. accepts applicants regardless of race, color, national origin, sex, sexual orientation, veteran status or disability. The
fol owing criteria are used to determine acceptance: The applicant (1) must be able to benefit from the camp program, (2) must be adaptable to the
group living environment, (3) must not be physical y, verbal y, or sexual y abusive, (4) must have no history of arson or fire setting AND (5) must be
free of conditions and behaviors that might not be manageable in a camp setting. (See Program Eligibility Standards)
We (camper and parent/guardian) wish the applicant who signs below to participate in the Mt. Hood Kiwanis Camp program. We recognize that there
may be risk of injury during such participation and that certain dangers and accidents may occur. We further agree that each person participating in
the program must fol ow safety instructions, remain in areas designated by staff, and refrain from behavior that is harmful to himself/herself or others.
Failure to do so wil be cause for the camper's dismissal from the program. Please be aware that al of Mt. Hood Kiwanis Camp’s employees and
volunteers are mandatory reporters. Any concerns or al egations of abuse wil be reported directly to Department of Human Services and not to the
parents or caregivers of the camper.
In consideration of participation in the program, the camper and the camper’s parents hereby release and discharge the Mt. Hood Kiwanis Camp,
Inc., its officers, agents and employees; Kiwanis Clubs and their members; Portland State University, its employees and students; the State of
Oregon; the U.S. Forest Service and the agents and insurers of each of them, from any and al claims, arising from negligence including but not to
exceed ordinary negligence as al owed by Oregon state law, or breach of contract, because of any injury to the applicant during participation in the
program. Further, we agree to defend and indemnify the Camp, its officers, agents and employees; Kiwanis Clubs and their members; Portland State
University, its employees and students; the State of Oregon; the U.S. Forest Service and the agents and insurers of each of them, from actions for
damages or expense caused to other participants in the program which are caused by our camper.
I give permission for the Camp Director or his/her designee to search camper’s belongings, with camper present, when the health, wel -being or
safety of the camper or others requires a search.
I give permission for camper to be transported in camp-designated vehicles for off-site trips and for emergency or routine medical care.
I understand that the Mt. Hood Kiwanis Camp must provide a safe and cooperative group experience for al campers and that the applicant may be
dismissed from the program for reasons including behavior, il ness, injury or homesickness.
I understand that any refund for a camper leaving the camp early wil be prorated based on the number of nights spent at camp.
I have read and understand the fee structure, refund and balance-due policies and agree to pay as stated.
I do ____ do not ___ give my permission for my camper to call me collect from camp.

I understand that photographs may be taken at the camp showing the campers and camp staff in their usual camp activities. Some photographs wil
be used by Mt. Hood Kiwanis Camp and Portland State University for both promotional and educational purposes in printed materials, on our website
and in other media. I also understand that other parents, guests, staff, and volunteers wil be taking pictures as wel and it is out of Mt. Hood Kiwanis
Camp’s control to monitor the use of these pictures.
Yes, I agree that Mt. Hood Kiwanis Camp, Inc. and Portland State University may take photographs of campers in usual camp activities and that the
pictures may be used for the above purposes as deemed proper by Mt. Hood Kiwanis Camp, Inc. and/or Portland State University.
Initial here if you give permission: __________

No. I do not give permission for Mt. Hood Kiwanis Camp, Inc. and Portland State University to use photographs of the camper for promotional or
educational purposes.
Initial here if you do NOT give permission: ___________

I DO HEREBY ACKNOWLEDGE that I have careful y read al of the foregoing information and I understand and agree to its contents.
x_________________________________________________________________ _______________________________________________
Signature of Parent or Guardian
I understand and agree to fol ow the policies of the Mt. Hood Kiwanis Camp and any restrictions placed on my camp activities. x_________________________________________________________________ _______________________________________________ Signature of Camper


Elr 2009-4.indb

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