Microsoft word - medical recommendation revised 10-9-07.doc

To Parent(s)/Guardian(s): Complete this section and give this form (FORM 2) and a copy of your
completed CAMPER HEALTH HISTORY FORM (FORM 1) to your child’s health-care provider for review.
Developed and reviewed by: American Camp Association, Dates will attend camp: from ______________to_____________ American Academy of Pediatrics Council on School Health, & Camper Name: _____________________________________________________________ Male Female Birth Date ____________ Age on arrival at camp ________ Mail this form to the address below
Camper home address: ________________________________________________________ ____________________________________________________________________________ Custodial parent(s)/guardian(s) phone: (_______)______________ (_______)____________ Parent(s)/guardian(s) stop here. Rest of form to be completed by medical personnel.
The following non-prescription medications are Medical Personnel: Please review the CAMPER HEALTH HISTORY FORM (FORM 1) and complete all
commonly stocked in camp Health Centers and are remaining sections of this form (FORM 2). Attach additional information if needed.
used on an as needed basis to manage illness and injury. Medical personnel: Cross out those items the
Physical exam done today: Yes No (If “No,” date of last physical: ___________)
camper should not be given.
ACA accreditation standards specify physical exam within last 24 months.
Phenylephrine (Sudafed PE) CalamineLotion Weight: _______ lbs Height: _____ft_____in Blood Pressure_______/_______ Pseudoephedrine (Sudafed)OTC antihistamines Allergies:
To foods (list):
To medications: (list):
Lice shampoo or scabies cream (Nix or Elimite) To the environment (insect stings, hay fever, etc.– list):
Other allergies: (list):
Describe previous reactions:
Diet, Nutrition: Eats a regular diet. Has a medically prescribed meal plan or dietary restrictions:(describe below)
The camper is undergoing treatment at this time for the following conditions: (describe below) None.
No daily medications. Will take the following prescribed medication(s) while at camp: (name, dose, frequency—describe below)
Other treatments/therapies to be continued at camp: (describe below) None needed.
Do you feel that the camper will require limitations or restrictions to activity while at camp? No Yes

If you answered “Yes” to the question above, what do you recommend? (describe below—attach additional information if needed)

“I have reviewed the CAMPER HEALTH HISTORY FORM (FORM 1), and have discussed the camp program with the camper’s
parent(s)/guardian(s). It is my opinion that the camper is physically and emotionally fit to participate in an active camp program (except as

noted above.)
Name of licensed provider (please print): __________________________________Signature: _________________________________Title: _________ Office Address_____________________________________________________________________________________________________________ Telephone: (________)_____________________ Copyright 2008 by American Camping Association, Inc. Rev. 2/07 LEE/EAW.


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