Download Med Form - Beaver Cross Ministries

BEAVER CROSS CAMPS CAMPER MEDICAL FORM
Beaver Cross Camps, 575 Burton Road, Greenwich NY 12834
phone: 518-692-9550 | fax 518-692-8777 | [email protected]
Register online at www.beavercrossministries.org
Camper Name__________________ _____________ Cabin/Group__________________ Session____________
This side to be completed by a parent or legal guardian, and returned prior to your child’s camp session.
New forms are required yearly.
Camper Name___________________________________ Date of Birth_____________ Age_____ Sex_____
Home Address_______________________________________________________________________________
Street
City
State
Zip
Mother's Name__________________________ Phone______________________ _______________________
First Number
Second Number
Father's Name___________________________ Phone______________________ _______________________
First Number
Second Number
Additional Emergency Contact__________________________________ Phone__________________________
Medical Insurance Carrier_____________________________ Card holder’s Name ________________________
Policy# _______________________________________________ Group # _____________________________
Permission for Camp Activities: Typical camp activities at include supervised hiking, swimming, boating, high
ropes, climbing tower, sports, archery, crafts, music, worship and field trips. My signature below indicates my
child has my permission to engage in all camp activities on and off camp grounds, and to be transported to, and
participate in, outings and field trips off Christ the King/Beaver Cross grounds under the supervision of the Camp
staff except at note below:
________________________________________________________________________
________________________________________________________________________
Parental Concerns: List concerns you, as parents/guardians, believe the Camp Staff should be aware of
including emotional or behavioral issues, eating disorders, bedwetting, nightmares, home sickness and the like.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Authorization for Emergency Medical Treatment: I give the staff of Christ the King/Beaver Cross, a ministry
of the Episcopal Diocese of Albany, permission to act for me on behalf of my child for treatment at a medical
facility and to arrange necessary related transportation. In the event I cannot be reached in an emergency, I give
permission to the attending physician to administer tests and treatment for my child. I understand that I am
responsible for all health related costs incurred, and that I fully release Beaver Cross and the Episcopal Diocese of
Albany from liability in connection with health related decisions made for your child on your behalf. I understand
that all medications, including over-the-counter, must be kept in the Health Officer’s office with the exception of
inhalers and epi-pens.
Meningococcal Meningitis Response: This question is required by the NYS Department of Health for campers
who will attending 7 or more consecutive nights at Camp.
_____My child had the meningococcal meningitis immunization within the last ten years on _____________
_____I have read, or have had explained to me, the information regarding meningococcal meningitis disease.
I understand the risks of not receiving the vaccine. I have decided that my child will not obtain
immunization against meningococcal meningitis disease.
Parent's Signature___________________________________________________ Date____________________
Updated 2-11-16
This side must be completed by a licensed Physician, Physician’s Assistant, or Nurse Practitioner within one year
of the first camp session the camper is attending. Attach a copy of this child's immunization record.
Individualized Health History and Physician’s orders for _________________________________
Camper name
Health History
Asthma/Breathing Difficulty
Seizures
Infectious Diseases
Serious Injuries
Heart Condition
Surgery
Diabetes
Major Orthodontia Work
Allergies
Other Health Concerns?
________________
Date of Birth
(Y) (N) Description
Standard over-the counter medications are available in the Camp Infirmary, and will be distributed by the Camp RN if
approval is indicated by the camper’s Physician. The dosage and schedule will be dispensed per label by weight and age
unless otherwise noted by the camper’s Physician.
Drug Name
Acetaminophen (Tylenol)
Ibuprofen (Advil)
Benadryl
Halls Cough Drops
Regular Strength Tums
Triple Antibiotic Ointment
Hydrocortisone 1%
Physician’s Order
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Dosage
Schedule
Comments
Please list the prescription medications and parent-supplied non-prescription medications and vitamins the camper will
bring to camp. All medications must be in original containers, and will be kept secured in the Camp Health Office.
Drug Name
Dosage
Schedule
Comments
Please list any limitations or restrictions to camp activities for the camper.
_____________________________________________________________________________
_____________________________________________________________________________
Physician’s Printed Name____________________________________________
Phone_________________________
Address___________________________________________________________________________________________
Physician’s Signature_______________________________________________ Examination Date_________________
Updated 2-11-16