Youth organizations using the school forest must use this form. This health information must be on file at the school forest during the time that the group is using the facility. This form must be kept by the youth group leader for 2 years. Name __________________________________ Age ____________ Phone _____________________ Address ___________________________ City _____________________ State ______ Zip _______ Organization __________________________________________ Date of Program _____________ Emergency Contact Person ________________________________ Phone ____________________ Insurance Company ___________________________ Identification Number _________________ Does the camper take any medication(s)? Yes ______
My child has my permission to receive emergency medical care:
_________________________________________
1. All medications (including over the counter pills, vitamins and treatments) must be turned over to the health care supervisor upon registration. 2. All medications will be administered under the direction of the health care staff. 3. All medications should be labeled clearly with the camper’s name, name of the drug, dosage and time to be taken. Please provide an adequate supply. 4. Do not record insulin schedule below. Dosage Date Time Date Time Initials Medication
Comments: __________________________________________________________________________ _____________________________________________________________________________________
5. Does the camper experience any side effects from the medication? Yes ______ No ______ (i.e.: mood or behavior changes, upset stomach, diarrhea, etc.) If yes, what should be done about this? _____________________________________________ 6. List below any special instructions or additional information regarding the medication that would be helpful to the health care supervisor. _________________________________ __________________________________________________________________________________ 7. Allergies: Do you have any allergies (e.g. bees, drugs, food, etc.)? If so, what are they? __________________________________________________________________________________ __________________________________________________________________________________ 8. Medications: Are you taking medication (e.g. Tylenol, Orthonovo 777, Proventil, etc.)? If so, what are they? What are they for? ___________________________________________ __________________________________________________________________________________ 9. Chronic Illness: Do you have any chronic illness (e.g., diabetes, epilepsy, asthma, etc.)? ____________________________________________________________________________ _________________________________________________________________________________ 10. Physical Conditions: Do you have any physical conditions that might limit or prevent you from participating in certain physical activities? If so, please describe. ___________ _________________________________________________________________________________ 11. Injuries: Have you experienced any injuries (e.g. dislocations, sprains, etc.) within the last three years? If so, list here and identify when the injuries occurred and the extent or the severity of the injury. Have you fully recovered from this injury? ______________ __________________________________________________________________________________ 12. Physician: Have you been treated by a physician in the past year? Have you been hospitalized within the past year? If so, explain. ___________________________________ _________________________________________________________________________________ Have you had any of the following in the last 24 hours?
The Please Don't Forget Me List Sacred Sites of Peru & Machu Picchu; Merging with the Divine October 7th-18th, 2009 Led by: Sheri Rosenthal DPM I am so delighted that you are joining us for the upcoming excursion! I ask you to carefully read the following information to ensure that your experience is as physically comfortable and spiritually rewarding as possible. Each Jou