Ramah day camp in nyack

RAMAH DAY CAMP in NYACK
CAMPER Winter Address
Summer Address
PHOTO New York, NY 10027
PART I. (A parent or legal guardian should complete this page of the form)
______________________________________________________________________________________________ Camper Last Name ______________________________________________________________________________________________ Address Home Phone: ( )____________________ _____ Mother’s Name: __________________________________ Father’s name: __________________________________ Emergency Contacts: In case of medical emergency, we will make every effort to contact you. Please prioritize the
numbers where we should reach you: (In addition to parents/guardian, please include at least one emergency contact.)
~ Please call this contact 1st: Name:_____________________ Phone ____________________ Cell __________________ ~ Please call this contact 2nd: Name_____________________ Phone ____________________ Cell __________________ ~ Please call this contact 3rd : Name_____________________ Phone ____________________ Cell ________________ HEALTH INSURANCE CO. (Attach Copy of Insurance Card – Front & Back):________________________________
____________________________________________________________________________________________________ Address of Ins. Co.____ ___________________________________ Phone #_____________________________________
Name of Policy Holder: ______________________________________________________________________ Does your Insurance Co. have to be called before seeing a doctor? YES [ ] NO [ ] Significant medical conditions for which your child is currently being treated:______________________________
________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Allergies (to include medication, food and other miscellaneous allergies):
List all known
Describe reaction and management of the reaction
_________________
______________________________________________________________________________ _________________
______________________________________________________________________________
_________________ ______________________________________________________________________________ Tylenol or Benadryl Permission:
•
I hereby grant permission to the medical staff at the Ramah Day Camp in Nyack to administer Tylenol or its equivalent in
the appropriate dosage as deemed necessary. YES ______
I hereby grant permission to the medical staff at the Ramah Day Camp in Nyack to administer Benadryl or its equivalent in
the appropriate dosage as deemed necessary.
In case of medical/surgical emergency, I hereby give permission to the physician selected by the Ramah Day Camp director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child. (Please note that in such emergency cases it is Ramah Day Camp policy to make every effort to reach the parent in advance.) I also give my permission to the physician selected by the Ramah Day Camp director to advise and treat my child for any illness or medical condition while he or she is in the program. ___________________________________________________ Signature of Parent or Legal Guardian
(Continued on page 2)
TO BE COMPLETED BY YOUR PHYSICIAN:
I have examined the camp participant: YES ______________ NO _______________ Date of last examination: _________________________ BP _____________
Weight _____________ Height ______________
~ In my opinion, the above applicant IS or IS NOT able to participate in an active camp program.
~ With the exception of routine medical care, the applicant is under the care of a physician for the following conditions: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ~ Current treatment includes: ________________________________________________________________________ ______________________________________________________________________________________________ ~ Known allergies: ________________________________________________________________________________ ______________________________________________________________________________________________ • Description of any limitation or restriction on camp activities:
Dietary: ______________________________________________________________________________________ ______________________________________________________________________________________________ Other: ________________________________________________________________________________________ ______________________________________________________________________________________________ • Medications being taken:
This person takes NO medications on a routine basis.
This person takes the following prescription medications: Med #1 ___________________ Dosage ____________________ Specific times taken each day____________________
Reason for taking ___________________________________________________________________________ ___________________________________________________________________________ Med #2 ___________________ Dosage ____________________ Specific times taken each day ___________________
Reason for taking ___________________________________________________________________________ ___________________________________________________________________________ Med #3 ___________________ Dosage ____________________ Specific times taken each day ___________________
Reason for taking ___________________________________________________________________________ (Please continue on page 3)
TO BE COMPLETED BY PHYSICIAN (Please use black ink):
Which of the following has the participant had?
• Immunization Record
_______ ___German Measles ______________ ___________Seizure Disorder ______________ ~ Date of last TB Mantoux Test _____________ ~ Details of above:
_____________________________________________ _____________________________________________ General Questions:
“YES” questions in the space
1) Had any recent injury, illness or infectious disease? …………. below (noting the number of the
2) Have a chronic or recurring illness / condition?………………… questions).
3) Ever been hospitalized? …………………………………………. 4) Ever had surgery? ………………………………………………… headaches? ………………………………………. 6) Ever had a head injury? …………………………………………… _____________________________
7) Ever been knocked unconscious ………………………………. 8) Wear glasses, contacts or protective eye wear? .……………. 9) Ever had frequent ear infections …………………………………. 10) Ever passed out during or after exercise? ……………………… 11) Ever been dizzy during or after exercise? ………………………. 12) Ever had seizures? ………………………………………………… 13) Ever had chest pain during or after exercise? …………………. 14) Ever had high blood pressure? …………………………………. 15) Ever been diagnosed with a heart murmur? ……………………. 16) Ever had back problems? ………………………………………… 17) Ever had problems with joints (e.g., knees, ankles)? …………. 18) Have an orthodontics appliance being brought to camp? ……. 19) Have any skin problems (e.g., itching, rash, acne)? …………. 20) Have diabetes? …………………………………………………… 21) Have asthma? ……………………………………………………. 22) Had mononucleosis? ……………………………………………. 23) Have problems with diarrhea / constipation? ………………….
(Please continue on page 4)
TO BE COMPLETED BY PHYSICIAN:
Recent Surgical procedures:
______________________________________________________________________________________________ ______________________________________________________________________________________________ ================================================================================================ Name of family physician: ___________________________________________ Phone: _______________________ Address: _______________________________________________________________________________________ Name of family dentist/orthodontist: __________________________________ Phone: _______________________ Address: _______________________________________________________________________________________ This health history is correct and complete as far as I know, and the person herein described is fully immunized and
has permission to engage in all camp activities except as noted.

______________________________________ _____________________________________ _________________
Signature of Physician
Name of Physician (Please print)

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Source: http://www.ramahnyack.org/pdf/nyack_campermedical_2007.pdf