Camper Health Form
P.O. Box 1513 Cherry Hil , NJ 08034
www.barclayfarm.org Mail or BFSC Day Camp Email: [email protected] c/o Chris Shull 120 Deerfield Drive Fax: (567) 429-6052 Cherry Hill, NJ 08034 Child’s Name: ______________________________________, Date of Birth: ____________________ Address: __________________________________________________________________________ Parent or Guardians: __________________________ (#1); ____________________________ (#2)
Home Phone: _________________________ (#1); ____________________________ (#2) Work Phone: __________________________ (#1); ____________________________ (#2) Cell Phone: ___________________________ (#1); ____________________________ (#2)
In an emergency notify: ____________________________ Relationship to Child: _________________ Address: __________________________________________________________________________ Phones Home#: __________________; Work#: __________________; Cell #: __________________ Does child have physical, medical or emotional problems? Yes No If yes, please describe:
__________________________________________________________________________________
Does your child take any medications on a daily basis? Yes No If yes, list medications:
__________________________________________________________________________________
Does your child have any known allergic reactions to the following? Bee Sting Peanuts
Chocolate Penicillin Other Foods Other Drugs Seasonal Allergens Other
What is your child’s usual reaction? Hives Rash Anaphylaxis Other
Please describe other: _______________________________________________________________
The Camp Directors have permission to administer Benadryl if needed for nonspecific rashes or minor
allergic reactions? Yes No (Dosage based on child’s age or weight.)
The Camp Directors have permission to administer the following for headaches or minor discomforts?
HEALTH HISTORY: (Please check – giving appropriate dates.)
Frequent Colds __________________________ Kidney Trouble _________________________
Chicken Pox ____________________________ Frequent Sore Throats ___________________
Measles _______________________________ Tuberculosis ___________________________
Bronchitis _______________________________ Mumps _______________________________
Heart Trouble ___________________________ Whooping Cough _______________________
Sinusitis _______________________________ Constipation ___________________________
Abscessed Ears _________________________ Convulsions ___________________________
Poliomyelitis ____________________________ Diabetes ______________________________
Athlete’s Foot ___________________________ Stomach Upsets ________________________
Serious Ivy, Oak, Sumac Poisoning _________________________ _________________________
Operations or Serious Injuries_________________________ ______________________________
Any Allergies_________________________ ___________________________________________
Emotional Stability: Much Some Little None _____________________________________
Maturity: Much Some Little None ______________________________________________
Any Personal Problems: Much Some Little None __________________________________
Any Behavior Problems: Explain _______________________________________________________
Any Learning Problems: Explain _______________________________________________________
Recommendations/Restrictions (diet, medicine, swimming, running, etc.) _______________________
_________________________________________________________________________________
_______________________________________________________________________________________________________________
IMMUNIZATIONS: (Write approx. date of immunization.) DPT Series Tetanus _________________________
Polio Measles (MMR) _______________________ Haemphilis (Hib) __________________________
Is child up to date with Tetanus vaccine or Tetanus booster shot? Yes No
In case of emergency, I understand every effort will be made to contact parents/guardian of camper. In the event that I cannot be reached, I hereby give permission to the physician selected by the Director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child, as named above. Parent Signature: ___________________________ Date: ______________________________ Physician’s Name: __________________________ Physician’s Phone: ___________________ Physician’s Signature: ______________________ Date of Last Physical: _________________ Medical exam is preferred but not required by state law. Doctor’s signature is only necessary if camper requires medical clearance to participate in camp activities. 2013 Page 2 of 2
Neue Krankheiten wie das Ebolafieber oder die Lungenentzündung SARS tauchen immer wieder auf. Die Medizin versucht daher, den Rüstungswettlauf zwischen Mensch und Mikrobe grundsätzlich besser zu verstehen und neue Abwehrstrategien zu entwickeln. Sie liegen vier Wochen im Koma – und als Sie schen zu befallen. Diese Gelegenheit ergab sich aufwachen, ist die Welt menschenleer: Ihre Be-erst
Chin Ho sp Pharm J ,2005 Aug ,Vol 25 ,No . 8Allen R , Myers A R , Frederick H , et al . The relatio nship of ser2um uric acid to risk facto rs in co ro nary heart disease [ J ] . Am JPuig J G , Mat eo s F , Bo un A , et al . Effect of Ep ro sartan andLo sartan o n uric acid met aboli sm in patient s wit h essential hyper2tensio n[J ] . Hypertens , 1999 , 17 (7) : 1033Edwareds RW , Trizna