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St Andrews Camp & Retreat Center
1280 State Rte 49, Cleveland, NY 13042
(315) 675-9771
[email protected]
Medical Evaluation
Counselor /
Staff/VOLUNTEE
RS
Prescription Medications brought to Camp
Any prescription medications brought to Camp must be brought to the Health Director immediately
upon registration. No medications, prescription or over-the-counter (OTC), may be kept by
participants.
Prescription medications must remain in their original container(s), must clearly state the camper‘s
name, contents, and the physician‘s instructions; and must include the dates of use, name of
prescription, dosage amount, and time(s) of day to be administered.
The use of medication is closely monitored to protect all campers, and must be stored under lock in
the Health Office. Please reclaim it from the Health Director at the close of the camper‘s session.
Insurance Coverage
All counselors and staff must carry their own medical insurance. The camp provides only secondary
insurance for accidents
Rev: Jan 2012
Counselor / Staff Application
Part 03
Pg 1 of 3
St Andrews Camp & Retreat Center
1280 State Rte 49, Cleveland, NY 13042
(315) 675-9771
[email protected]
New York State required Meningococcal Meningitis Form.
Camper
Last Name:
Date of Birth
First Name:
/
/
Parent:
Last Name:
First Name:
TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN
MENINGOCOCCAL (One dose within 10 years recommended by NYS PHL §2167)
CHECK ONE (1) BOX ONLY
□ I have received Quadrivalent polysaccharide vaccine (Menomune™) Date :
/
/
□ 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 I (my child) will not obtain immunization
against meningococcal meningitis disease.
Signed
Date :
/
/
Rev: Jan 2012
Counselor / Staff Application
Part 03
Pg 2 of 3
St Andrews Camp & Retreat Center
1280 State Rte 49, Cleveland, NY 13042
(315) 675-9771
[email protected]
Meningococcal Disease
What is meningococcal disease?
Meningococcal disease is a severe bacterial infection of the bloodstream or meninges (a thin lining covering the
brain and spinal cord) caused by the meningococcus germ.
Who gets meningococcal disease?
Anyone can get meningococcal disease, but it is more common in infants and children. For some adolescents, such as
first-year college students living in dormitories, there is an increased risk of meningococcal disease. Every year in the
United States, approximately 2,500 people are infected and 300 die from the disease. Other persons at increased risk
include household contacts of a person known to have had this disease, immunocompromised people, and people
traveling to parts of the world where meningococcal meningitis is prevalent.
How is the meningococcus germ spread?
The meningococcus germ is spread by direct close contact with nose or throat discharges of an infected person.
What are the symptoms?
High fever, headache, vomiting, stiff neck and a rash are symptoms of meningococcal disease. The symptoms may
appear two to 10 days after exposure, but usually within five days. Among people who develop meningococcal disease,
10 to 15 percent die in spite of treatment with antibiotics. Of those who live, permanent brain damage, hearing loss,
kidney failure, loss of arms or legs, or chronic nervous system problems can occur.
What is the treatment for meningococcal disease?
Antibiotics, such as penicillin G or ceftriaxone, can be used to treat people with meningococcal disease.
Should people who have been in contact with a diagnosed case of meningococcal meningitis be treated?
Only people who have been in close contact (household members, intimate contacts, health care personnel
performing mouth-to-mouth resuscitation, daycare center playmates, etc.) need to be considered for preventive
treatment. Such people are usually advised to obtain a prescription for a special antibiotic (either rifampin,
ciprofloxacin or ceftriaxone) from their physician. Casual contact as might occur in a regular classroom, office or
factory setting is not usually significant enough to cause concern.
Is there a vaccine to prevent meningococcal meningitis?
In February 2005, the CDC recommended a new vaccine, known as Menactra™, for use to prevent meningococcal
disease. The previous version of this vaccine, Menomune™, was first available in the United States in 1985. Both
vaccines are 85 to 100 percent effective in preventing the four kinds of the meningococcus germ (types A, C, Y, W-135).
These four types cause about 70 percent of the disease in the United States. Because the vaccine does not include type
B, which accounts for about one-third of cases in adolescents, it does not prevent all cases of meningococcal disease.
Is the vaccine safe? Are there adverse side effects to the vaccine?
Both vaccines are currently available and both are safe and effective vaccines. However, both vaccines may cause mild
and infrequent side effects, such as redness and pain at the injection site lasting up to two days.
Who should get the meningococcal vaccine?
The vaccine is recommended for all adolescents entering middle school (11-12 years old) and high school (15 years old),
and all first-year college students living in dormitories. Also at increased risk are people with terminal
complement deficiencies or asplenia, some laboratory workers, and travelers to endemic areas of the world.
However, the vaccine will benefit all teenagers and young adults in the United States.
What is the duration of protection from the vaccine?
Menomune™, the older vaccine, requires booster doses every three to five years. Although research is still pending, the
new vaccine, Menactra™, will probably not require booster doses. As with any vaccine, vaccination against meningitis
may not protect 100 percent of all susceptible individuals.
How do I get more information about meningococcal disease and vaccination?
Contact your family physician or your student health service. Additional information is also available on the Web
sites of the New York State Department of Health, www.health.state.ny.us; the Centers for Disease Control and
Prevention, www.cdc.gov/ncid/dbmd/diseaseinfo; and the American College Health Association, www.acha.org.
Rev: Jan 2012
Counselor / Staff Application
Part 03
Pg 3 of 3
St Andrews Camp & Retreat Center
1280 State Rte 49, Cleveland, NY 13042
(315) 675-9771
[email protected]
CAMP HEALTH EXAMINATION ( Counselor / Staff )
This side to be filled in by counselor / staff and checked with health care provider at time of examination
Name
(Last)
Birth Date
(Initial)
(First)
Parent or Guardian (or Spouse)
Phone (
Sex
Age
)
Home Address
(Street & Number)
(City)
Emergency Notification:
(1)
(State)
Relationship:
(Zip)
Phone:
Address:
Cell Phone:
or (2)
Relationship:
Phone:
Address:
Cell Phone:
HEALTH HISTORY: (Check – giving approximate dates)
Date
Date
If camper has an epipen please bring It to
camp. It will be kept by the Nurse.
Date
ALERGIES
Ear Infection
Diabetes
Mumps
Seasonal
Allergies
Scarlet Fever
Behavior
Issues
Asthma
Insect Stings
Bee/Wasp
Seizure
Measles
Chicken
Pox
Nuts
Anemia
Eczema
German
Measles
Sulfa
Penicillin
Latex
Other
drugs
(name)
Operations or Serious Injuries (Dates)
Chronic or Recurring Illnesses
Other Diseases or Details of Above
Regularly Taken Medications (including vitamins or other Over-The –Counter)
Insurance Company:
Address:
Phone
Policy Holder:
ID#
Group #
PLEASE ENCLOSE
COPY OF
INSURANCE CARD
AUTHORIZATION
This health history is correct so far as I know, and the person herein described can engage in all prescribed camp activities, except as noted
by me and the examining physician. In the event of an EMERGENCY, I hereby give permission to the physician selected by the camp director
to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for me as named above.
Counselor/Staff
Signature
Date
Health care provider Signature confirming accuracy of above information
Please sign the bottom of each page
Rev: Jan 2012
Date
Counselor / Staff Application
Part 04
Pg 1 of 3
St Andrews Camp & Retreat Center
1280 State Rte 49, Cleveland, NY 13042
(315) 675-9771
[email protected]
Name:
IMMUNIZATION HISTORY
Required immunizations must be determined locally. This is a record of dates of basic immunizations and most recent booster doses.
DTP Series
Booster
Tdap or Td Booster
Polio IPV (Sabin)
Booster
Mumps Vaccine (live)
German Measles (Rubella)
Measles Vaccine (live)
Measles / MMR (2nd)
Hep B (3)
HIB
Meningitis
Hep A
Hep A (2nd)
Varicella (2)
BCG
Last Tuberculin Test Date
Results:
X-ray results if PPD is poisitive
Other:
Other state or municipal examinations required for staff (if any)
MEDICAL EXAMINATION - To be filled out by licensed physician
This examination should be performed within 12 months of arrival at camp.
Examination for some other purpose within this period is acceptable.
Examination is for determining fitness to engage in strenuous activities.
Ht:
Wt:
B.P.:
Code:
Eyes
Glasses
Ears
Nose
Throat
S – Satisfactory
Teeth
Heart
Lungs
Abdomen
Hernia
Resp (R)
Pulse (P)
N - Not Satisfactory (explain)
Spine
Extremities
Skin
Temp (T)
O - Not Examined
Please Specify Alergies
Other (Please Specify)
General Appraisal:
Recommendations and restrictions while in camp.
Special Diet
Special Medicine (name it)
Swimming, diving
Strenuous activity
Emotional or psychological issues
Rev: Jan 2012
Counselor / Staff Application
Part 04
Pg 2 of 3
St Andrews Camp & Retreat Center
1280 State Rte 49, Cleveland, NY 13042
(315) 675-9771
[email protected]
Other
I have examined the person herein described and I have reviewed his medical history. It is my opinion that he is physically able to engage in
camp activities, except as noted above.
Health care provider Signature confirming accuracy of above information
Please sign the bottom of each page
Rev: Jan 2012
Counselor / Staff Application
Date
Part 04
Pg 3 of 3
St Andrews Camp & Retreat Center
1280 State Rte 49, Cleveland, NY 13042
(315) 675-9771
[email protected]
Name:
Prescription Medications:
Health Care Provider, please complete with patient’s current regimen for both scheduled and PRN
Medications.
Prescription Drug Name
Dose
Route
Schedule & Indications
Comments
Additional Orders:
Primary Health Care Provider:
Phone #:
Fax #:
License #:
Address:
Based on my knowledge of the applicant’s health and behavioral characteristics, in my position as
his/her primary care physician, I deem his/her attendance at a residential camp appropriate:
Health Care Provider’s
Signature
Date
Please sign the bottom of each page
Rev: Jan 2012
Counselor / Staff Application
Part 04
Pg 4 of 3