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Seven Hills/Goodyear Resident Camp - Health History Record REMEMBER NEW THIS YEAR – PLEASE DO NOT BRING FORMS TO CAMP Parents/Guardians: Your daughters’ health form must be mailed to our council office with your final camp payment on
or before June 6th. Only, if you register your daughter after June 6th, please bring this form to camp with you on opening day. Without this form your daughter cannot stay at camp. Please PRINT clearly and include area code with phone numbers. Parents/Guardians please sign, complete and send to: Rochester Service Center, 1020 John Street, W Henrietta, NY 14586, Fax: (585) 292-1086 -OR-
Buffalo Service Center, 3332 Walden Avenue, Suite 106, Depew, NY 14043, Fax: (716) 706-1359
Camper’s Name:
EMERGENCY CONTACT INFORMATION (PLEASE PRINT) Camper’s Name:
Parent/Guardian (1)
Address: (if different from the camper’s)
Parent/Guardian (2)
Address: (if different from the camper’s)
If parent/guardian is unavailable, notify:

Name of child’s physician:
EMERGENCY MEDICAL AUTHORIZATION In the event reasonable attempts to contact me or the emergency contacts at the above listed phone numbers have been unsuccessful, I hereby give GSWNY staff my consent to transport my child to an accessible hospital facility, and for administration of emergency medical treatment by any licensed physician, midlevel provider under physician direction, or dentist to order x-rays, routine tests, secure proper treatment for, order
injection, anesthesia, or surgery for my child. I understand I am responsible for the cost of medical care. To my knowledge the health form is correct and my child has permission to engage in all camp activities except as noted by me and or her physician. I also give permission to photocopy this form for out of camp trips and I understand the information on this form wil be shared on a "need to
Parent/Guardian Signature:
CAMPER’S PHYSICAL ISSUES + IMMUNIZATIONS: THIS SECTION TO BE COMPLETED BY PARENT ILLNESSES AND INJURIES
ALLERGIES
(Check those chronic or recurring il nesses that apply and (Check those that apply and specify nature of allergic Ear Infections __________________________ Heart Disease/Defect ____________________ Bleeding/Clotting Disorders _______________ Musculoskeletal Disorders ________________ Seizures ______________________________ Rubel a _______________________________ Rheumatic Fever _______________________ Insect Stings __________________________ Chicken Pox ___________________________ Operations/Serious Injuries _______________ In order for your daughter to stay at camp the New York State Health Department requires that the Immunization History be fil ed out completely with dates. OTHER HEALTH CONDITIONS
IMMUNIZATION HISTORY
(Check those that apply and add comments if applicable) Bed Wetting ___________________________ Constipation ___________________________ Hearing Impairment _____________________ Sickle Cell Disease ______________________ Special Dietary regimen __________________ Wears glasses/contact lenses _____________ Emotional Disorder _____________________ Fainting_______________________________ Menstrual Cramps ______________________ Motion Sickness ________________________ Nose Bleeds ___________________________ Sleep Disturbances ______________________ Restricted Activity: ______________________ CAMPER’S SPECIAL NEEDS: THIS SECTION TO BE COMPLETED BY PARENT (PLEASE PRINT)

Does your daughter experience any of the following?
Does your daughter eat a regular vegetarian/vegan diet? Does your daughter have special food needs? (Please describe below.) Yes
Does your daughter have any food allergies? (Please describe below.) Yes
Has there been any recent events in your child’s life (ex: death of a family member or pet) that may be concerning your child. Please explain:
Does your daughter have any restrictions while at camp? Please explain:
Are there any other concerns you would like to share? MEDICAL EXAMINATION: THIS SECTION TO BE COMPLETED BY PHYSICIAN (PLEASE PRINT) This Medical Examination to be completed by a licensed physician. This exam must be performed within 12 months of a child's arrival at camp. This is in compliance with an America Camp Association (ACA) regulation. If no, date of last physical ________________. If not, has she been told about menstruation? Is this child under a physician's care for any reason? Is this child under a psychologist's care? Are any prescribed medications not being taken during the summer months? Does the child have a self-carry statement for________? I have examined the individual described and reviewed her health history. This individual is in satisfactory health,
free from communicable diseases, and able to participate in camp activities.
MEDICATIONS AT CAMP: THIS SECTION TO BE COMPLETED BY PHYSICIAN (PLEASE PRINT)

STANDARD OVER THE COUNTER/PRN MEDICATIONS
(The following medications are available in the infirmary and will
be administered at the discretion of our health supervisor, if approval is indicated by the child’s health care provider.) Drug Name
Dosage Route
Schedule &
Healthcare
Indications
Provider Approval Comments

DID YOU KNOW? The NYSHD considers bug spray & suntan lotion over the counter medications. Please have your

child’s physician sign below authorizing use of these products while at camp.
Drug Name

Dosage Route
Schedule &
Healthcare
Indications
Provider Approval Comments

PRESCRIPTION MEDICATIONS
(Please complete the patient’s current regimen for both scheduled and PRN medications
– attach additional information if necessary). MEDICATIONS MUST BE SENT TO CAMP IN THEIR ORIGINAL PHARMACY
CONTAINERS WITH CAMPERS NAME ON THEM.
Drug Name

Dosage Route
Schedule &
Healthcare
Indications
Provider Approval Comments

Physician’s Name:


Physician’s Signature:


Office Number:

License Number:

Source: http://www.gswny.org/include/uploads/1/health%20form%20-%20seven%20hills%20goodyear%20resident%20camp.pdf

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