CAMPER HEALTH RECORD
WEST HAVEN CAMP
Camper Name______________________________________________Male_____ Female_____ Age_______
Last First
Date of Birth______________________________________________ MCP number ______________________________ Month / Day/ Year
Address_____________________________________________________________________________________________ Street or P.O. Box number Town Province Postal Code
Home phone number: ________________________________________
Names of parent(s) or guardian(s) and phone numbers at work:________________________________________________
Name and phone number of alternate contact:__________________________________________________________
We make every effort to accommodate campers with medical problems or disabilities. It is important for us to be aware of these in order to ensure the comfort and safety of your child. Use separate sheet if necessary.
Check any conditions that may be useful for the camp staff to know:
Bed wetting_____ Poor appetite______ Fear of dark______ Sleep walking______ Other (please describe)________________________________________________
Has camper had booster shots?___kindergarten__14-16yrs__
Allergies? Yes _____ No _____ Carries EPIPEN: Yes___ No ___
Allergy to drug(s) (specify)______________________________________________
Food Allergy:___________________ _____________________________________
Allergy to bee stings___________ Allergy to wasp stings_____________________
Other allergies (specify)________________________________________________
Type of allergic reaction (rash, hay fever, breathing difficulties, etc.) ___________________________________________________________________________
Does the camper have: Asthma _______________ Hay fever ______________
Does he/she use an inhaler (puffer)? Yes _____No______
Should he/she carry the inhaler for emergency use? Yes___No____
Is there any reason why the camper cannot participate in all camp activities?
(ie: swimming, canoeing, hiking, running, etc.) If so, please list any restrictions. _____________________________________________________________________________
Any medications to be given at camp ? Yes_____ No______ List prescription medications as well as any other medications that the parent wants to be given at camp if needed (such as benadryl, gravol, tylenol). Parents must discuss these with Camp Health Care staff on child’s arrival at camp.
Name of medication :________________________________Name of medication:________________________________ Times to taken:_____________________________________Times to be taken:__________________________________
Any special instructions:_____________________________ Any special instructions:___________________________
All medications brought to camp must be given to the health care worker at registration. Exceptions (1) epipens (2) Inhalers needed by camper for emergency use.
1. Send medication in pharmacy bottle with name of camper, medication and dosage information clearly visible.
2. Epipens & inhalers for emergency use should be carried in a fanny pack. (Two epipens may be necessary with severe allergies due to the distance from camp to hospital).
To the best of my knowledge, my child is in good health. I will notify the camp if my child is exposed to an infectious disease during the three weeks prior to arriving at camp. The camp health care worker has my permission to administer the medication as listed on the health care form. In case of emergency, I understand that every effort will be made to contact me (or contact person). In the event I cannot be reached, I hereby give my permission to the physician selected by the Camp Director and/or Health Care Worker to hospitalize, secure proper treatment, order injection, anaesthetic or surgery for my child:
PARENT’S SIGNATURE: ____________________________________
CAMP NUMBER______CAMP DATE____________________________
Please indicate if you wish to receive a call from the Health Care Coordinator prior to arrival at camp to discuss any health &/or other confidential issues: YES___NO_____
[Form revised April 1, 2007)