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Illinois Rainbow Leadership Camp Health Form
ALLERGIES (please include child’s reactions) Meds_____Food_____Contact_____Latex_____ Name ____________________________________ List:_____________________________________ _________________________________________ Birth date_________________________________ _________________________________________ Parent/Guardian____________________________ (Please bring all medications in original bottle we Address___________________________________ must know about everything including over the counter medications (see reverse for specific over __________________________________________ Phone:____________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ 1.________________________________________ __________________________________________ __________________________________________ __________________________________________ Home diet:_________________________________ 2.________________________________________ Please list all special diet requirements (i.e. Vegetarian, dairy intolerance, no caffeine, etc.) __________________________________________ __________________________________________ __________________________________________ __________________________________________ Diabetes_____Epilepsy/seizures______HTN_____ Cardiac______LungDisease______Asthma______ __________________________________________ Renal Disease______Cancer______Ulcers_______ Thyroid___Chickenpox____Measles/Mumps_____ Swimmer’s ear_________Ear infections_________ Policy Number:_____________________________ Cold/Cough/Sore Throat (last 2 weeks)__________ Pertinent family history______________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ health history is correct so far as I know, and the person herein described has permission to engage in all camp activities, __________________________________________ except as noted by me. I understand that the Illinois Rainbow __________________________________________ Leadership Camp staff includes a Registered Nurse and __________________________________________ Certified First-Aiders who will give care for usual & common medical issues and refer to the doctor on call as needed, SIGNATURE:______________________________ DATE:____________________________________ PLEASE COMPLETE REVERSE SIDE OF THE FORM
Illinois Rainbow Leadership Camp Health Form
The Illinois Rainbow Leadership Camp Nurse, Stacy Newton, RN, BSN, has my permission, should the need arise, to administer the following over the counter medications to my child, ________________________, (note, generic brand medications will be given): ___ Acetaminophen (Tylenol)
Signed: _______________________________, Parent / Legal Guardian Date: ____/____/____.
The following OPTIONAL Emergency Authorization is suggested by BroMenn Medical Center, Normal,
Illinois (the hospital closest to Camp)
AUTHORIZATION FOR EMERGENCY MEDICAL AND/OR SURGICAL TREATMENT FOR A MINOR CHILD AND DESIGNATION OF PERSON AUTHORIZED TO GIVE SUBSTITUTE CONSENT FOR KNOW ALL MEN BY THESE PRESENTS that I (we), of (city) ________________________, In the County of _____________________ and State of Illinois, do hereby direct BroMenn Healthcare to accept the consent of Stacy Newton R.N.,BSN, Illinois Rainbow Leadership Camp Nurse, an adult, for any and all medical treatment which may be needed by my child, __________________________________, when I (we) am (are) unavailable and efforts to contact me (us) are unsuccessful. I hereby authorize Stacy Newton R.N., BSN, Illinois Rainbow Leadership Camp Nurse, to make any and all necessary health care decisions on behalf of my child which my be required during my daughter’s attendance at Illinois Rainbow Leadership Camp, June 21-27, 2009. _______________________________________________ DATE_______________________ SIGNATURE OF PARENT/GUARDIAN WITNESS OR NOTARY

_______________________________________________ DATE_______________________
SIGNATURE OF WITNESS OR NOTARY
__________________________________________
Relationship of Witness OR Notary Stamp

Source: http://www.iliorg.org/2009_camp_healthform.pdf