Ymcaspringfield.org

YMCA Camp Wakonda
Physician Recommendation
Please fill out form completely and return to: YMCA Camp Wakonda The following non-prescription medications To Parent(s)/Guardian(s): Complete shaded sections and give this form and are commonly stocked in camp Health Cen- a copy of your completed Health history and Release Form to your child’s ters and are used on an as needed basis to Medical personnel: Cross out those items Custodial parent(s)/guardian(s) phone: (_______)________________________ Medical Personnel: Please review the Health History and Release Form and complete all un-shaded sections of this form. Lice Shampoo / scabies cream (Nix/Elimite) Attach additional information if needed. Physical exam done today:  Yes  No (if “No” date of last physical exam date _____/______/___ __ ) No Known Allergies Food Medication Environment (insect stings, hay fever, etc) Other Please list & Describe reactions for all that apply: MI Diet, Nutrition: Eats a regular diet. Has a medically prescribed meal plan or dietary restrictions: (describe below) The camper is undergoing treatment at this time for the following conditions:  None  Yes (describe below) Medication:  No daily medications.  Will take the following prescribed medication(s) while at camp: (name, dose, frequency—describe below) Other treatments/therapies to be continued at camp:  None Yes (describe below) Do you feel that the camper will require limitations or restrictions to activity while at camp?  No  Yes “I have reviewed the Health History and Release Form, and have discussed the camp program with the camper’s parent(s)/ guardian(s). It is in my opinion that the camper is physically and emotionally fit to participate in an active camp program Name of licensed provider: _______________________________________Signature:____________________________________________Title :__________ YMCA Camp Wakonda
Health History & Release form Please fill out form completely and return to:
Male  Female Birthdate__ / / _ Age at Camp _ _ Parent/guardian with legal custody to be contacted in case of illness or injury: Second parent/guardian or other emergency contact: Additional contact in event parent(s)/guardians(s) cannot be reached: Allergies: No Known Allergies This camper is allergic to: Food Medication Environment (insect stings, hay fever, etc) Other (Please describe below what the camper is allergic to and the reaction seen.) Diet, Nutrition: This camper eats a regular diet. This camper eats a vegetarian diet. This camper has special food needs. Restrictions:  I have reviewed the program and activities of the camp and feel the camper can participate without restrictions  I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations. (Please describe below) Medical Insurance information: This camper is covered by family/hospital insurance Yes No First (Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable) Insurance Company Phone Number ( _____) Parent/Guardian Authorization for Health Care: This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person descr ibed has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician s elected by the camp to order x-rays, routine test, and treatment related to the health of my child for both routine health care and in emergency situat ion. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for and order injectio n, anesthesia or surgery for this child. I understand the information on this form will be shared on a “need to know” basis with camp staff. I give permission to st photocopy this form. In addition, the camp has permission to obtain a copy of my child’s health record from providers who tr eat my child and L these providers may talk with the program’s staff about my child’s health status. If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendan ce. Are the campers immunizations up to date? Yes No If your camper has not been fully immunized, please sign the following statement: I understand and accept the risk to my child from not being fully immunized. Check “Yes” or “No” for each statement. Explain “Yes” answers below. Passed out/had chest pain during exercise? Had mononucleosis during the last 12 months? Yes No If female, have problems with menstruation? Have problems with falling asleep/sleepwalking? Yes No Had asthma/wheezing/shortness of breath? Have problems with diarrhea/constipation? Wear glasses, contacts or protective eyewear? Yes No Traveled outside the country in past 9 months? Yes No Please explain “Yes” answers in the space below, noting the number of the question. For travel, please name countries visited and dates. _____ Mental, Emotional, and Social Health: Check “Yes” or “No” for each statement. Has the camper: Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)? Ever been treated for emotional or behavioral difficulties or an eating disorder? During the last 12 months, seen a professional to address mental/emotional health concerns? Had a significant life event that continues to affect the campers life? (history of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others) Please explain “Yes” answers in the space below, noting the number of the question. The camp may contact you for additional details. _____  This camper will not take any daily medications while attending camp  This camper will take the following daily medication(s) while at camp: “Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Please provide enough medication to last the entire week. All medication must be in original packaging/bottle that identifies the prescribing physician (if a prescrip-tion drug), name of medication, dosage, and frequency of administration. Name of Medication Lunch Dinner Bedtime Other_______________ Lunch Dinner Bedtime Other_______________ Lunch Dinner Bedtime Other_______________ The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Check those the camper should NOT be given. Phenylephrine decongestant (Sudafed PE) Pseudoephedrine decongestant (Sudafed) Diphenhydramine antihistamine / allergy medication (Benadryl) Dextromethorphan cough syrup (Robitussin DM) Lice shampoo or cream (Nix or Elimite) Bismuth subsalicylate for diarrhea (Pepto-Bismol)

Source: http://ymcaspringfield.org/pdf/camp/Health%20Form%202012.pdf