2014 fourpagehealthform

SPROUT CREEK FARM
34 Lauer Road
Poughkeepsie, NY 12603
845.485.8438
Student’s Name ____________________Session: ____________ Birthdate ________________ Home Address _________________________________________________________________ _______________________________________________ Telephone _____________________ Father’s name - Business/Address _________________________________________________ _______________________________________________ Telephone _____________________ Mother’s name -Business/Address__________________________________________________ _______________________________________________ Telephone _____________________ Cell phone number(s): _______________________________________________________ In case of emergency, if parents cannot be reached, call __________________________________ Relationship to child __________________________ Telephone _______________________ E-Mail Address (Please Print)____________________________________ Health Insurance Carrier ________________________Policy Number _____________________ GENERAL HEALTH INFORMATION
1. Has your child had any serious illness, injury, or surgery in the past year? Yes No If yes, explain.___________________________________________________________________ 2. Has your child had his/her appendix removed? Yes No 3. Does your child have allergies? Yes Please specify allergy and reaction: ________________________________________________ ______________________________________________________________________________ Does your child have any special dietary needs? Please specify.———————————— 5. Does your child have any chronic mild illness (i.e. nervous stomach) or physical idiosyncrasy that we should know about? Yes__________No_______ There are four pages to this Health Form.
IMMUNIZATION RECORD
(The New York State Health Department requires that dates be given or that
medical records showing immunization dates be attached.)
Name of child’s doctor ___________________________________________________________ Telephone _____________________________________________________________________ PARENT’S WAIVER FOR EMERGENCY TREATMENT
In case of emergency, if parents are not available, I hereby authorize the Director of Sprout Creek Farm or her designee to have my child _________________________ treated by a physician and/or admitted to the emergency room of a hospital. Parent Signature __________________________________________________________ This waiver shall apply November 2013 through September 2014
Please note: According to New York State Law, the camp nurse MAY NOT
administer ANY non-prescription-over-the-counter medicine without the child’s
physician's signature. While this has been true for prescription medicine, it is now a
requirement for non-prescription medicine as well. All Overnight campers must
have this form signed and returned whether or NOT parents want non-prescription
drugs administered.
Please be sure a Doctor signs page four of this form
INDIVIDUAL ORDERS for NAME_______________________________________________________ DOB_____________________________WEIGHT___________________ The following order form must be completed and signed by the child’s physician. If the child will be taking any prescription medications while at camp, the doctor must also complete the reverse side of this form. The camp nurse is only permitted to dispense medications to a child that is listed on this form by the child’s doctor. Standard and Over the Counter/PRN Medications The following medications are available in the Infirmary and will be
administered at the discretion of an RN, IF approved by the camper’s healthcare provider.
Required :
Doctor’s
Signature_____________________________________________Date____________
Prescription Medications Please complete with the patient’s current regiment for both scheduled and PRN medications.
Additional Orders as deemed necessary by health care provider to be implemented by an RN. Doctor’s Name__________________________________Phone #_______________________ Address________________________________________License #_______________________ Signature_______________________________________________________Date____________ Please note: According to New York State Law, the camp nurse MAY NOT administer ANY
non-prescription-over-the-counter medicine without the child’s physician's signature.
While this has been true for prescription medicine,
it is now a requirement for non-prescription medicine as well.
All Overnight campers must have this form signed and returned
whether or NOT parents want non-prescription drugs administered.
Revised: November 2013

Source: http://www.sproutcreekfarm.org/2014_health_forms.pdf