Microsoft word - staff camp medicals complete-2014 (1).doc

2014 JCC of Mid-Westchester Camps
Staff Medical Form
Return to Camp Office by May 30, 2014
Name __________________________________________________________________ Birth date _______________ Age at camp __________ Home address ________________________________________________________________________________________________________ Custodial parent/guardian ______________________________________________________________ Phone ___________________________ Home address ________________________________________________________________________________________________________ (if different from above) Business address ____________________________________________________________________________Phone ____________________ Second parent or guardian or emergency contact _____________________________________________________________________________ Address ___________________________________________________________________________________Phone _____________________ Business address ____________________________________________________________________________Phone _____________________ If not available in an emergency, notify: Name _______________________________________________________________________________________________________________ Relationship _______________________________________________________________________________ Phone _____________________ Address _____________________________________________________________________________________________________________
Insurance Information

Is the participant covered by family medical/hospital insurance?
Parent/Guardian Authorizations: This health history is correct and complete as far as I know. The person herein described has
permission to engage in all camp activities except as noted. I hereby give permission to the camp to provide routine health care,
administer prescribed medications and seek emergency medical treatment including ordering x-rays or routine tests. I agree to release
any records necessary for insurance purposes. I give permission to the camp to arrange necessary related transportation for me/my
child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to hospitalize,
secure proper treatment for, and to order injection, anesthesia or surgery for the person named above.
Signature of parent /guardian _____________________________________________________________ Date __________________
Health History

The following must be filled in by the parent/guardian. The intent of this information is to provide camp health care personnel the background to
provide appropriate care. Keep a copy of the completed form for your records. Any changes to this form should be provided to camp health
personnel upon participant’s arrival in camp. Provide complete information so that the camp may be aware of your needs.
Allergies List all known.
Describe reaction and management of reaction. Medication allergies (list)
_____________________________________ ________________________________________________________________________
_____________________________________ ________________________________________________________________________
_____________________________________ ________________________________________________________________________
_____________________________________ ________________________________________________________________________
Food allergies (list)
_____________________________________ ________________________________________________________________________ _____________________________________ ________________________________________________________________________ _____________________________________ ________________________________________________________________________ _____________________________________ ________________________________________________________________________ Other allergies (list) – include insect stings, hay fever, asthma, animal dander, etc.
_____________________________________ ________________________________________________________________________
_____________________________________ ________________________________________________________________________
_____________________________________ ________________________________________________________________________
_____________________________________ ________________________________________________________________________
Medications Being Taken

Please list all medications (including over-the-counter or nonprescription drugs) taken routinely. Keep the medication that you are bringing to
camp in its original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage and
the frequency of administration (for Staff under the age of 18 years old).
Med #1 ___________________________________Dosage _________ Specific times taken each day ________________________________ Reason for taking ___________________________________________________________________________________________________ Med #2 ___________________________________ Dosage _________ Specific times taken each day _______________________________ Reason for taking ___________________________________________________________________________________________________ Med #3 ___________________________________ Dosage _________ Specific times taken each day _______________________________ Reason for taking ___________________________________________________________________________________________________ Attach any additional pages for more medications. Identify any medications taken during the school year that participant does/may not take during the summer: __________________________________________________________________________________________________________________
Explain any dietary restrictions.

Explain any restrictions to activities (e.g. what cannot be done, what adaptations or limitations are necessary)
General Questions
Had any recent injury, illness or infectious Have a chronic or recurring illness/condition? Ever been diagnosed with a heart murmur? Ever had problems with joints (e.g., knees, Wear glasses, contacts or protective eye wear? Ever passed out during or after exercise? Had mononucleosis in the past 12 months? Ever been dizzy during or after exercise? Had problems with diarrhea/constipation? Ever had emotional difficulties for which Please explain any “yes” answers, noting the number of the question you are referring to. Which of the following has the participant had? Please give all dates of immunization for: Date of last test ______________________ Use this space to provide any additional information about the participant’s behavior and physical, emotional or mental health about which the camp should be aware. Name of family physician _____________________________________________________ Phone __________________________ Address _____________________________________________________________________________________________________________ Name of family dentist/orthodontist ____________________________________________________ Phone _____________________________ Address _____________________________________________________________________________________________________________ Health Care Recommendations
by Licensed Medical Personnel

Date of Examination _______________________________________
The applicant is under the care of a physician for the following conditions: ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Recommendations and Restrictions at Camp
Medications to be administered at camp ___________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Any medically prescribed dietary restrictions ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Known allergies ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Description of any limitation or restriction on camp activities ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Additional information for health care staff at camp ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ I have examined the child herein described and have reviewed his/her health history. It is my opinion that he/she is physically able to engage in all camp activities, except as noted. _______________________________________________________ ____________________________________________________ ____________________________________________________________________________________________________________________ Street ______________________________________________________________ ___________________________________________________________ JCC of Mid-Westchester Camps 2013
Medication Procedures
Dear Parent/Guardian: It is possible for you to have your child given both non-prescription and prescription medications, if needed. Please follow these guidelines. I. Acetaminophen (Tylenol) and Benadryl Only The medications that are available are acetaminophen (i.e. Tylenol, etc.) for fever or pain, and diphenhydramine hydrochloride (i.e. Benadryl, etc.) oral liquid for allergic reaction or itching. These medications will be given after you have been contacted in order to prevent medication duplication. In the unlikely event of a severe allergic reaction, Benadryl may be given with only your written permission. Even though we will call you before administering these medications, we are required to have it in writing in advance. If you wish to give permission for these medications, please complete the attached Non-Prescription Medication Permission Form and have your child’s physician sign this form. Please return it to our office once you have both signatures but no later than May 31. II. Prescription Medication(s) and Other Non-Prescription Medication(s) If your child has an illness that is being treated with either a prescription or a non-prescription medication the camp nurse or designee can administer it, if needed, during camp hours. In order to comply with Health Department regulations, please do the following if you need us to give medication to your child. A. Contact the camp nurse to obtain necessary form and instructions. B. Ask your physician for a written order for any medication, either prescription or non-prescription that your child needs to take during camp hours. In addition, ask the physician to write down any restrictions for your child while your child is taking the medication. Remember, if your child is placed on a medication, ask the physician when he puts the child on any medication, to write you a note for the school to dispense the medication, if your child needs it during the camp hours, which includes the dates and times for the medication to be given. Give the physician’s note to the camp nurse with the medication. C. In addition, you must sign an administration of medication form giving the camp nurse your permission to give your child the medication. D. You must send the medication in the original container you received it in from the pharmacy or store. When you have a prescription filled, ask the pharmacist to put it into two containers - one for those doses to be given during the camp time and the other for those taken at home. On the container for prescription medications must be the child’s name, medication name, dosage of medication, how the medication is to be given and frequency of administration. Containers saying administer as directed cannot be used by the camp nurse. On the containers of non-prescription medications, please write your child’s name. All medications will be kept locked in the health office. E. If possible, please bring the medication to the camp when it is the first time it is to be given. DO NOT SEND MEDICATION IN YOUR CHILD’S BAG. This is for the safety of all the children. If you can’t bring it please give it to the adult who is bringing your child to camp that day and ask them to bring the medication to the camp nurse. The above guidelines are those required for the safe administration of medications to your child. It is in your child’s best interest that you follow them. If you have any questions, please call 472-3300. Extensions for camps are below. Yours truly, _____________________ Non-Prescription Medication Permission Slip (Under 18 years of age)
Please sign your name and have your child’s physician sign for the medication(s) you want to have administered, if needed, to your child by the camp nurse or designee. In most instances, the medication will not be given to your child until after you have been called and given your verbal permission. However, in the case of an allergic reaction, the camp will make every effort to contact you, but will administer Benadryl if it is necessary as long as you and your child’s physician have signed this form. Child’s Name: ____________________________Age:_____________ Weight:___________ Address: ____________________________________________Zip:______________ I give permission to the camp nurse or designee to administer the following medication(s), if needed, according to the dosage listed, to my child as named above: 1. Acetaminophen (I.E. Tylenol, etc.), dosage listed below, every 4-6 hours as needed for pain or fever: Ages 12 and over (over 100 lbs.) 380-650 mg. PO _______________________________ _______________________________ Parent’s/Guardian’s _______________________________ _______________________________ Parent’s/Guardian’s Printed Name _______________________________ _______________________________ Date 2. Diphenhydramine Hydrochloride (Benadryl) 12.5-25 mg. PO for allergic reaction. _______________________________ _______________________________ Parent’s/Guardian’s _______________________________ _______________________________ Parent’s/Guardian’s Printed Name _______________________________ _______________________________ Date Topical Medications that may be administered with parent/guardian and physician written permission to
your child when at camp are listed below. Please note that written permission for use of these medications
is an updated New York State policy as of 2011. We need both you, as your child’s parent/guardian and
your child’s physician to sign for each topical medication.
1. Bacitracin Ointment
2. Hydrocortisone Cream 0.5%
3. Calamine Lotion
Administration of Prescribed Medication (Under 18 years of age)
The camp has developed a policy regarding the administration of medications which is consistent with New
York State guidelines, accepted medical practice and children’s safety. Students are not to carry any
medication for self-administration MEDICATION MUST BE DELIVERED TO THE CAMP AND TAKEN

Thank you for your cooperation.
I hereby request that the camp nurse (or Director’s designee) administer medication as prescribed by my
child’s physician.
Student’s Name __________________________Date of Birth_______________
Parent/Guardian daytime telephone number_____________________________
I hereby release the employees of the JCC of Mid-Westchester from any and all liability arising from the
administration of this medication.
Date_____________ Parent/Guardian Signature__________________________
Patient______________________ Diagnosis____________________________
Medication __________________ Dose__________ Frequency_____________
Dates for Administration: From_________________ Through_______________
If PRN, signs and symptoms for administering medication___________________
Possible Side Effects_______________________________________________
Restrictions(what and how long?)______________________________________
M.D. Name (PRINT)_____________________________Tel. #_______________
N.Y.S. Reg. #______________________________
Date________________ M.D. Signature________________________________
IMPORTANT: Prescription medication must be in a PRESCRIPTION BOTTLE with a proper Pharmacist’s
label attached. Medication containers stating “give as directed” CANNOT be used by the JCC of Mid-
Westchester. The label must list the student’s name, medication, dosage, directions for use and the
physician’s name.



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