Microsoft word - 2010 camper application - additional forms.doc

Information Release Form
To help us determine if our camp is an appropriate setting for your child, we will need to access confidential information from your child’s physician, social worker, caseworker, therapist,
Below you will find a statement of consent. Please sign it, and include it in the completed
application packet you send back to us.
Thank your again for applying to Camp AmeriKids. If you have any questions, please do not I, _______________________________________________, give permission for _______________________________________________, _______________________, Name Physician, Social Worker/Case Worker/Therapist of ______________________________________, to provide information about ________________________________________. Parent/Guardian Signature: _____________________________ Date: _______________ Psychosocial History Form
PLEASE HAVE THIS FORM FILLED OUT BY THE CHILD’S SOCIAL WORKER,
CASEMANAGER OR THERAPIST. IF UNAVAILABLE, FORM MAY BE FILLED OUT BY
PARENT/GUARDIAN.
CHILD’S NAME____________________________________________DATE______________
Please complete the following questions fully. The more information you are able to
provide us, the more prepared we will be to deliver a safe and fun-filled summer experience
to this child at camp.
In what capacity do you know the child? How well do you know the child? What is the child’s living situation? What are the dynamics in the family? Please tell us about the child’s progress and behavior in school: What are the current stressors in the child’s life? Please tell us some positive things about the child: Please give us three words you would use to describe the child: Do you have any concerns about how the child will behave at camp this summer? Please provide any helpful suggestions for working with the child at camp: Any other comments you would like to share with us: Completed By: ____________________________________ Title: ____________________ Phone: ___________________________________Email:____________________________ Individual Orders Form

Individual orders for
Name: _________________________________________

DOB: __________________Wt: ________Ht:_________

The following form must be completed and signed by the child’s physician. If the child will
be taking any prescription medication while at camp, the doctor must also complete the reverse
Individual Orders for Over the Counter/ PRN Medications
(The following medications are available in the infirmary and will be administered at the discretion of a camp physician or nurse):
Drug Name
Dosage and
Indications
Comments
Schedule
Health Care
Provider
(Please circle
(hives, insect bite) Continued on next page

Prescription Medications
Please complete with the patient’s current regime for both scheduled and PRN medications.
Drug Name Route
Indications
Comments
Health Care
Schedule
Provider

Additional Orders: (As deemed necessary by health care provider to be implanted by RN)

Camper’s Health Care Provider Name:
Meningitis Information Sheet
I am writing to inform you about menigococcal disease (a potentially fatal bacterial infection commonly referred to as meningitis) and a new law in New York State. On July 22, 2003, the New York State Public Health Law (NYS PHL) was amended to include section 2167 requiring overnight children’s camps to distribute information about meningococcal disease and vaccination to the parents or guardians of all campers who attend camp for 7 or more nights. This law became effective on August 15, 2003. Camp AmeriKids is required to maintain a record of the following for each camper: • A response to receipt of meningococcal meningitis disease and vaccine information signed by the camper’s parent/guardian; AND • Information on the availability and cost of meningococcal meningitis vaccine • A record of meningococcal meningitis immunization within the past 10 years, OR • An acknowledgement of meningoococcal meningitis disease risks and refusal of meningococcal meningitis immunization signed by the camper’s parent/guardian. Meningitis is rare. However, when it strikes, its flu-like symptoms make diagnosis difficult. If not treated early, meningitis can lead to swelling of the fluid surrounding the brain and spinal column as well as severe and permanent disabilities, such as hearing loss, brain damage, seizures, limb amputation and even death. Cases of meningitis among teens and young adults 15-24 years of age have more than doubled since 1991. The disease strikes about 3,000 Americans each year and claims about 300 lives. A vaccine is available that protects four types of the bacteria that cause meningitis in the United States---types A, C, Y and W-135. These types account for nearly two thirds of meningitis cases Information about the availability and cost of the vaccine can be obtained from your local healthcare provided and by visiting the manufacturer’s website www.meningitisvaccine.com. Camp AmeriKids is not able to provide this vaccine.
Please complete the Meningococcal Vaccination Response Form and return it to:


To learn more about meningitis and the vaccine, please feel free to contact Gaby Moss, and/or
consult your child’s physician. You can also find information about the disease at the New York State Department of Health website: www.health.state.NY.us, and Meningitis Vaccination Form
New York State Public Health Law requires the operator of an overnight children’s camp to maintain a completed response form for every camper who attends camp for seven (7) or more
Check one box and sign below.
______My child has had the meningococcal meningitis immunization (Menonmune TM / Menactra TM) within the past 10 years. Date received: ________________________ [Note: the vaccine’s protection lasts for approximately 3-5 years. Revaccination may be _____ 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. Signed: _________________________________________ Date: ___________________ Camper’s Name: _________________________________ Date of Birth: ____________ Mailing Address: __________________________________________________________ HIPAA FORM
I, ________________________________________________, HEREBY AUTHORIZE AND DIRECT the CAMP AMERIKIDS, INC. Camp Physician TO USE OR DISCLOSE MY PROTECTED HEALTH INFORMATION (as defined herein) to the Camp AmeriKids Camp Director as is deemed necessary by the director or the Camp Physician for the safe conduct of In addition, I authorize the Camp Physician to request, secure and use information regarding any prior and ongoing health condition and any prior and ongoing care and treatment from al health care providers holding such information ( my “Protected Health Information”) including, but not limited to: history and physical examination; admission and discharge summaries; operative reports; progress notes and nursing notes; laboratory reports; radiology reports; immunization records; bil ing summaries; consultation reports; pathology reports; psychological and psychiatric assessments; and medications. I understand that in the event I was treated for drug or alcohol abuse, psychiatric condition, communicable diseases, including HIV/AIDS, this information wil be included as part of my I understand that the Camp Physician may not condition treatment or eligibility to participate in the Camp AmeriKids program on my signing this authorization. I understand that this authorization is intended for use or disclosure of my Protected Health Information to the extent of and as permitted by the Standards for Privacy of Individual y Identifiable Health Information (the so-cal ed “Privacy Rule”) issued by the U.S. Department of Health and Human Services to implement the requirement of the Health Insurance Portability and Accounting Act of 1996 (“HIPAA”). I have been given an opportunity to inquire and request information to my satisfaction regarding the requirements of the above law and regulations. I understand that this authorization wil expire automatical y on the later of 90 days from the date hereof or the end of the camp period, and I also understand that I may cancel and revoke this authorization at any time effective upon my delivering written notice thereof to the Camp Physician except to the extent there has already been use or disclosure in reliance on this (Signature of Individual Camper or Legal y Guardian) Camper’s Social Security Number: _____________________________________ Camper’s Date of Birth: ______________________________________________

Source: http://www.campamerikids.org/files/2010_additional_required_camper_forms.pdf