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CAMP OAKHURST HEALTH SCREENING FORM
CAMP DATES______________________
CAMPER’S NAME:___________________________________________________________________________________________________________________
AGE:_______________________________________________________ DATE OF BIRTH:________________________________________________ SEX: M / F
CHURCH/CITY:______________________________________________________________________________________________________________________
PARENT/GUARDIAN’S NAME AND PHONE:______________________________________________________________________________________________
IF YOU OBSERVE ANY ILLNESS, COMMUNICABLE (INFECTIOUS) DISEASE, OR INJURY AS
LISTED BELOW IN THE THREE BOXES, DESCRIBE THE ITEM THAT WAS CIRCLED ON THE LINES
PROVIDED BELOW.
B.
A.
ILLNESS (in the last 48 hours)
C.
COMMUNICABLE DISEASE
EXAMPLES:
INJURY EXAMPLES:
NAUSEA, VOMITING,
MEASLES, MUMPS, RUBELLA, POLIO,
CASTED FRACTURES,
DIARRHEA, FEVER,
HEPATITIS, TETANUS, DIPTHERIA,
RECENT HEAD INJURIES,
MENINGITIS, PERTUSSIS, INFLUENZA,
AND/OR LACERATIONS
TUBERCULOSIS
THAT HAVE STITCHES OR
ACTIVE
STAPLES –
MAY INCLUDE:
SORE THROAT, RASH,
OPEN
SORES, PINK EYE,
COUGH NOT RELATED TO
ASTHMA
(ON MEDICATION)
MUST BE
OR
CLEARED BY DOCTOR
INACTIVE (NEGATIVE CHEST X-­RAY)
If any items are circled in either column A or B please have the individual refrain from coming to camp.
_______________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
*ALL ABOVE INFORMATION WILL BE KEPT CONFIDENTIAL AND ONLY SHARED WITH CAMP OAKHURST STAFF OR YOUR CHURCH COUNSELOR,
IN ORDER TO PROVIDE ADEQUATE HEALTH CARE FOR YOUR CHILD WHILE AT CAMP. THANK YOU.
SIGNATURE OF HEALTH SCREENER:_______________________________________________________________________________________Date ___________________________
Official Use:
Reviewed
/
/
Supervisor _____________________________________________________________________________________
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