Summer-games.tk

Summer Games 2013
CAMPER HEALTH HISTORY AND AUTHORIZATION


This form is MANDATORY and must be completed by the legal guardian of all persons (child and adult)
attending Summer Games. This form is REQUIRED at the time of camper check-in and the “Camp
Authorization” (back page) MUST BE SIGNED.

Completed
Name of Participant:_____________________________________ Birth date: ________________ Spring 2013:_____________
Home Address (street address, city, state, zip): ________________________________________________________________
Custodial Parent/Guardian: _________________________________________________ Home Phone: ____________________
Work Phone: _______________________________ Other Phone: ____________________________________ Address (street address, city, state, zip): _______________________________________________________________
OTHER Parent/Guardian: _________________________________________________ Home Phone: ____________________
Work Phone: _______________________________ Other Phone: ____________________________________ Address (street address, city, state, zip): _______________________________________________________________
EMERGENCY CONTACT NAME (Not Parent): __________________________________________________________________
Phone: ___________________________________ Relationship to Camper: ___________________________
IS PARTICIPANT COVERED BY HEALTH INSURANCE
_____ YES
If yes, carrier or policy name: ________________________________________________________________________ Policy Number: __________________________________ Policy Holder: ___________________________________ Date of Birth of Policy Holder: _______________________ Relationship to Camper: ___________________________ Mailing Address of Insurance Company: _______________________________________________________________ Policy Holder SS #: _______________________________ Camper SS # : ___________________________________
ALLERGIES – Describe CAUSE, REACTION and TREATMENT
________________________________________________________________________________ Insect Bites/Stings: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Other Allergies or Reactions: ________________________________________________________________________ ________________________________________________________________________________________________ Summer Games 2013


Name of Participant:_____________________________________
DIET RESTRICTIONS – The following restrictions apply to my camper:
Other (describe): _________________________

HEALTH CONDITIONS – Please indicate if your camper has any of the following and how it is best handled:

Please explain all that you have marked: _____________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
*(If you have ever been diagnosed with asthma by a physician and have ever had medication including tablets, nebulizers,
or inhalers, you MUST bring such treatment with you to camp or you will not be allowed to register!)

Describe any past/recent medical treatment or illness: ___________________________________________________________
Are the participant’s immunizations current?
Date of last tetanus shot: ___________________________ (Must be within past 10 years, if over 01 years contact physician) Date of last health exam: ___________________________ *You will be contacted if: Your child is exposed to a communicable disease Outside medical attention is necessary (e.g., if we transport him/her to hospital, doctor) Your child is having disciplinary problems that jeopardize the safety of other participants MEDICATIONS – Participant’s Name: ____________________________________
_________________________________________________________________________________________________________
ALL medications (prescription, non-prescription, vitamins, etc.) must be in their original containers and turned into camp
health care personnel at the time of camper check-in. ALL medications are collected, stored and distributed by camp
health care personnel.

Medication: _____________________ Dose: __________ Breakfast: _____ Lunch: _____ Dinner: _____ Bedtime: _____ Medication: _____________________ Dose: __________ Breakfast: _____ Lunch: _____ Dinner: _____ Bedtime: _____ Medication: _____________________ Dose: __________ Breakfast: _____ Lunch: _____ Dinner: _____ Bedtime: _____ Medication: _____________________ Dose: __________ Breakfast: _____ Lunch: _____ Dinner: _____ Bedtime: _____ Any scheduled medications that will NOT be taken at camp? _____________________________________________________ RESTRICTIONS – Please indicate if any physical, mental, or emotional conditions that could/would restrict activity while at camp. If there are conditions, what is the best way to handle restriction? _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Summer Games 2013

Name of Participant:_____________________________________
Please write YES or NO next to the following OTC (over the counter) medications your child may or may not be given:
Family Physician: _________________________________________ Phone: _______________________________ Family Dentist: ___________________________________________ Phone: ________________________________ CAMP AUTHORIZATION
The undersigned represents that he/she is the custodial parent/legal guardian of the above identified participant. The camper has my/our permission to attend the camping session from June 24, 2013 to June 28, 2013 at FFA/FCCLA Camp in Covington, Georgia. This permission is given by me/us with full knowledge of the conditions and activities contemplated during each session. The participant has no physical or mental disabilities that would impair his/her participation except as noted above. I/We will not hold the camp, conference, or camp personnel liable for injuries suffered as a result of the camper’s own voluntary actions. I give permission and consent for _____________________________________________ to participate in all activities and to allow photographs, videotapes, and interviews to be taken during the camping session. I further give permission and consent to any such photographs, videotapes, or interviews to be published and used to illustrate, report, promote and advertise the camp. Use of any such photographs, videotapes, or interviews may include, but is not limited to use in websites, catalogues, brochures, flyers, and general promotional materials. The participant is currently taking only medications listed above. The camper has no allergies known to me/us except as noted on this form. The health information/history is correct as far as I/we know. In the event of illness or injury I/we authorize they physician and/or hospital to undertake such treatment of and perform such services (including surgical) for the participant as are reasonably indicated by the circumstances. My child will be riding home with ___________________________________________ Phone Number: _____________________ Signature of LEGAL Parent/Guardian OR Adult __________________________________________ Date: ___________________ Signature of 2nd LEGAL Parent/Guardian _______________________________________________ Date: ___________________

Check in Screening – STAFF USE ONLY

Any allergies? _______________________________
Recent exposure to contagious disease? _______________________ Are all meds checked in? ______________________ Consent sections filled out and complete? ______________________

Source: http://summer-games.tk/wp-content/uploads/2013/03/SGCamperHealthHistoryandAuthorization2013.pdf