Microsoft word - camper health form - 2011dec.docx

Camper Health Form
For Use at Carson Springs and Linden Valley Baptist Conference Centers
And with other Ministries of the EXECUTIVE BOARD OF THE TENNESSEE BAPTIST CONVENTION Return Completed Event:_____________________Dates:___________________Location:____________________ Camper Name: ________________________________________________________________ First Name Middle Initial Last Name Your church
group leader for
Date of Birth: __________/________/___________________ ! Boy ! Girl inclusion with
church roster
Parents/Guardians: _____________________________________________________________ Questions?
Preferred Phone #: (______)______________ Alternate Phone #: (______)________________ Church_______________________________________________________________________
About health care for short-term camper stays:
• Campers should arrive ready to participate in the program. Should your camper be unable to participate, inform your church group leader about specific limitations. A separate form (Participation and Release and Assumption of Risk Agreement) is required for participation in camp activities. • Campers should bring – and use – insect repellent (minimum 30% DEET) and sun screen (minimum 30 SPF). • Unless otherwise instructed in writing on this form, all camper medications wil be collected and dispensed according to your instructions by the designated camp medical person. • In case of emergency, your attorney-in-fact wil either call the local ambulance service or have the child transported to a clinic or hospital which may be at least 15-20 minutes from the camp.
Camper Health Background
1. Date (month & year) of camper’s most recent tetanus immunization: _______________________________________ 2. Is this camper allergic to any food or medication? . ! Yes ! No If YES, name the item and indicate the reaction: _____________________________ ! Intolerance ! Anaphylaxis _____________________________ ! Intolerance ! Anaphylaxis 3. Does this camper have asthma? . ! Yes ! No If YES, will the camper carry a rescue inhaler during the camp session? . ! Yes ! No If YES, does the camper need staff help to use that rescue inhaler? . ! Yes ! No If YES, what triggers the camper’s asthma? _______________________________________________________ 4. If there is a question about the camper’s health and/or in an emergency, your attorney-in-fact wil make an attempt to contact you. Please provide emergency contact information for a custodial parent who wil be available via phone while Name of Parent: _______________________________________________________ Phone: (_____)________________________ Health-Care Providers:
Name of camper’s primary doctor(s): __________________________________________ Phone: (________) _______________________________
Name of camper’s dentist(s): _________________________________________________ Phone: (________) _______________________________ Name of orthodontist(s): _____________________________________________________ Phone: (________) _______________________________ 5. Medication: “Medication” is any substance a person takes to maintain and/or improve health. This includes vitamins & natural remedies. Send medications in original pharmacy containers with labels which show the camper’s name and how much medication should be given. Provide enough of each medication to last the entire time the camper wil be at camp.
_____ This camper WILL NOT take any daily medications while attending camp.
____ This camper wil take the following daily medication(s) while at camp. 8#&9-,%&0%)&2$%4*7$-% :&;%*,%*2%4*7$-% %The following non-prescription medications may be stocked in the camp First Aid Center and are used on an as needed basis to manage il ness and injury. Cross out those the camper should not be given.
Diphenhydramine antihistamine/allergy medicine (Benadryl) Dextromethorphan cough syrup (Robitussin DM) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) 6. What else should we know about your child? Please write additional information about your child’s health that may impact your child’s participation in our program including special dietary needs: (attach a separate sheet if needed).
!"#$%&'()*+,%&-.%(#/,)01&.2%).1(#
• I hereby appoint the Camp Manager, Camp Director and/or the Camp Nurse of the Executive Board camp attended by the minor camper listed on this form, as my attorney-in-fact and vest any of them with authority to authorize any necessary medical treatment • I understand that the camp may not be able to accommodate the special needs of the minor campers such as dietary needs or • I understand that I have purchased through the Executive Board of the Tennessee Baptist Convention, by means of the camp fee, a limited accident and il ness insurance policy. This policy may pay up to $2,500 of medical expense, with certain exceptions, for medical treatment required by the camper on this form. Pre-existing and self-inflicted injuries or il nesses are not covered by this policy. Furthermore, I agree to pay any and all medical expenses incurred in the care of this camper, not covered by this policy. • I agree that the camper is bound by the applicable policies and rules, as amended from time to time. Al decisions of the Camp • I agree to accept the risks to my child from not being fully immunized, if such is the case. • I understand that the camp has limited healthcare on site and that staff wil attempt to contact the indicated parent/guardian (a) in an emergency, (b) if questions about my child’s health may arise, and/or (c) when my child is unable to continue because of injury or illness. I acknowledge that the program wil handle medication as described and that information on this form wil be shared with • Further, as consideration for my minor child participating in the above mentioned event, I (1) acknowledge that there are certain
risks and dangers do exist, including, but not limited to, the hazards of being in a wilderness-type setting, the forces of nature, other acts of God and those existing because of the activities themselves and/or the content of the programs (e.g., the hazards of depending on other people); (2) do hereby assume all risks associated with participation in activities such as walking, running hiking, etc; and (3) do hereby hold harmless and agree to indemnify the Executive Board of the Tennessee Baptist Convention, the Tennessee Baptist Convention, their directors, officers, employees, volunteers or agents for any accident which may occur or injury which may be suffered directly or indirectly by my minor child from participating in activities. The terms hereof shall serve as a RELEASE AND ASSUMPTION OF RISK for my heirs, executors and administrators, for me, my child if my child is a participant, and my and my child’s personal representatives and next of kin in the event of my or my child’s death or incapacity. !Signature of Parent/Guardian: _____________________________________________________ Date: _________________

Source: http://www.tnbaptist.org/pdf/camp/camperhealth.pdf