Microsoft word - 2013 health form parts a & b.doc

St. Christopher Summer Camp Permission Form Complete Parts A, B & C and return by April 26, 2013 to: St Christopher Summer Camp Health Form, 2810 Seabrook Island Rd, Johns Island, SC 29455 Office (843)768-1337 Nurse: (843) 768-8519 Nurse Email: [email protected] PART A Reasonable precaution is exercised to ensure that St. Christopher is a safe place for your child. It is possible though, that illnesses or accidents requiring medical treatment may occur. It is vital that we obtain pertinent medical information in order to provide appropriate treatment, if needed. In the event that a child becomes ill or is injured, staff will act in accordance with the Camp Physician's "Standing Medical Orders" and the information provided on the Health History. If the situation warrants referral to a licensed physician or medical facility for further evaluation and treatment, we will attempt to contact the parent/guardian. If we are unable to contact the parent/guardian prior to necessary treatment, they will be notified as soon as possible after evaluation and treatment are completed. Medical providers will be instructed to send all bills directly to you. I authorize the physician selected by St. Christopher to secure and administer treatment, including hospitalization for _______________________ (Child’s name) if I cannot be reached in an emergency. I further authorize the Executive Director of St. Christopher, or his agent, to consent to any x-ray or treatment necessary for my child. I understand and accept that I will be billed directly by the providers of any medical treatment given and acknowledge financial responsibility for those bills. This form may be copied as necessary to provide medical care. I give permission for my child to participate in all Camp activities, except those noted on Part B, #11. Unless I inform the camp otherwise and in writing, I consent to photographs and interviews of my child that may be published to illustrate and promote St. Christopher/Diocese of South Carolina. I agree that my child may be given the following over-the-counter medications as needed, in age and weight appropriate dosages, while at St. Christopher: Ibuprofen (Advil/Motrin), Acetaminophen (Tylenol), Benadryl, cough drops/syrup, sore throat lozenges, antacid (Tums), anti-nausea liquid/pills (Dramamine), anti-diarrhea liquid/pills (Pepto Bismol, Imodium), stool softener, Calamine lotion, antibiotic ointment, topical insect bite relief, Hydrocortisone cream. These medications are kept in stock. Generics may be substituted. ** Please indicate on Part B, #5, if there are certain medications your child may not have. ___________________________________ _____________________________________ ________________ Parent or Guardian Printed Name Signature (Parent/Guardian) Child’s Name ________________________________________Date of Birth________________Session#___________ ________________________________________________________________________________________________ Home Address (of parent or guardian) City State Zip (______)_______-__________ Emergency contact if parent or guardian is not available: Name___________________________________________________ Relationship ______________________________ (______)_______-__________ Cabin Mate Request (Optional) 1. _______________________________2._____________________________________ Please note: (1) only two people may be listed (if more than two names are listed, we will only record the first two); (2) the request(s) must be mutually reciprocated on the other camper’s Permission Form; (3) this must be received by the April 26th deadline for health forms and final payment. Please check with the other camper(s) before submitting this request. **Please note: These forms cannot be submitted via fax or email** PART B Name ________________________________Date of Birth________________ Weight______ Session#____________ 1. Food, medication or other allergies including type of reaction and treatment required: If none, write “None” __________________________________________________________________________ __________________________________________________________________________ 2. Seafood/shellfish allergy: Yes No If yes, can child touch it? Yes No Can child eat it? Yes No 3. List all prescriptions and over the counter medications taken: If none, write “None” ________________________________________________________________________ ________________________________________________________________________ 4. Are you sending medications with your child? Yes No **If yes, you must complete PART C and return a copy with this form. Bring the original PART C with any updates, along with the medications, to registration. (See PART C for further instructions). 5. List medications you DO NOT want your child to have: ________________________________________________________________________ 6. Dietary restrictions or special diet requirements: If none, write “None” ________________________________________________________________________ ________________________________________________________________________ 7. Date of last tetanus vaccination______________ Are other immunizations current? Yes No 8. History of operations or serious illnesses (types/dates): If none, write “None” ________________________________________________________________________ ________________________________________________________________________ 9. Chronic/recurring illnesses (i.e. ear/throat infections, asthma, headaches, diabetes, seizures): If none, write “None” ________________________________________________________________________ ________________________________________________________________________ 10. Recent illnesses (past 3 months): If none, write “None” ________________________________________________________________________ 11. Restrictions regarding activities while at Summer Camp: If none, write “None” ________________________________________________________________________ Please have a physician sign below and/or attach a copy of a physical examination completed since April 1, 2012. Even if you sent this form or documentation of a physical examination last year, you must resubmit it this year. Please note that a record of immunization is not a physical and will not be accepted as such. Physician’s Authorization: "I have examined _______________________________, have found him/her free of communicable diseases and release him/her to participate in all summer camp activities except those noted on Part B, #11 above.” _________________________________ _________________________________ ___________________ Physician’s Printed Name Physician’s Signature Date


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