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Discoadventures.com

DISCOVERY ADVENTURES P.O. BOX 31 GLOUCESTER, MA 01930 (978) 283-3320 Child’s Name __________________________________________Age ___Ht___Wt___ Sex:M FName of Parent or Guardian ______________________________________________________________ Home Address __________________________________________________________________________ Phone (home) ____________________(work) _______________________(cell)______________________ Email Address___________________________________________________________________________ Emergency Contact ___________________________________________ Phone ____________________ HEALTH HISTORY OF CHILD (check – give approx. dates if applicable) If yes, please specify:_____________________________________________________________________________ If yes, please specify:_____________________________________________________________________________ Recent Surgeries or Serious Injuries (dates): _________________________________________________________________________________ Chronic/Recurring Injuries/Illnesses: ____________________________________________________________________________________ Current Medications? NO **YES Medication type:____________________________________________________________________ For what condition/illness is medication used? –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ***If you checked “YES” for medications, please complete our Medication Authorization FormThe Discovery Adventures Program is equipped with first aid kits that include the following over-the-counter medications which are approved by our consulting physician. All staff members are First Aid and CPR certified and present during camp hours. In the event of illness or injury, these medications are available for administration by staff members only. All medications are current, stored in water-proof containers, checked weekly and re-supplied or replaced when necessary. Please check and initial to approve the use of: Ibuprofen Non-Aspirin (Tylenol) Diphenhydramine (Benadryl, antihistamine) Pepto-Bismol Dramamine (non-drowsy, for motion sickness) Anti-diareal Name of Family Physician ________________________________ Phone____________________________Name of Dentist/Orthodontist____________________________ Phone ___________________________ Insurance Provider & Plan # ________________________________________________________________ Authorization for Treatment: I hereby give permission to the medical personnel selected by the program director to administer treat-ment and/or authorized medications and arrange necessary related transportation for my child in the event of an illness or injury. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the program director to secure and administer treatment, including hospitalization, for the person named above. Signature of Parent/Guardian ____________________________________Date ______________________ DISCOVERY ADVENTURES P.O. BOX 31 GLOUCESTER, MA 01930 (978)283-3320
DISCOVERY ADVENTURES SUMMER PROGRAM
HEALTH & IMMUNIZATION HISTORY
In accordance with Massachusetts Department of Public Health regulations, no child may attend camp without completed immunization/health forms on site. Your failure to submit this form will cause your child to be excused from camp. No refunds will be given. TO BE FILLED OUT BY PHYSICIAN

HEALTH CARE RECOMMENDATIONS BY LICENSED PHYSICIAN
I have examined the above applicant within the past two years.
In my opinion, the camper’s condition does preclude his/her participation in a day camp The applicant is under the care of a physician for the following condition: Current Treatment (Include current medications): Explanation of any related loss of consciousness, seizure activity or concussion: Does applicant have epilepsy? No Yes RECOMMENDATIONS AND RESTRICTIONS FOR CHILD:

IMMUNIZATION HISTORY

Hepititis B
DtaP DTP DT TD
Varicella
Chickenpox History
Check here if this person has a history of chickenpox. Other

Licensed Physician Signature:
Address:
Phone:
Date of Form Completion

(initial if completed by nurse or physician’s assistant)
DISCOVERY ADVENTURES
P.O. BOX 31
GLOUCESTER, MA 01930 (978)283-3320
MEDICATION AUTHORIZATION FORM
IF YOUR CHILD WILL BE NEEDING MEDICATION DURING CAMP SESSIONS, PLEASE COMPLETE THE
105 CMR 430.160(A) Medication prescribed for campers shall be kept in original containers bearing the pharmacy label, which
shows the date of filling, the pharmacy name and address, the filling pharmacist’s initials, the serial number of the prescription, the
name of the patient, the name of the prescribing practitioner, the name of the prescribed medication, directions for use and
cautionary statements, if any, contained in such prescription or required by law, and if tablets or capsules, the number in the
container. All over-the-counter medications for campers shall be kept in the original containers containing the original label, which
shall include the directions for use. Medications will be stored in locked containers.
105 CMR 430.160(C) Medication shall only be administered by the health supervisor* or by a licensed health care professional
authorized to administer prescription medications. If the health supervisor is not a licensed health care professional authorized to
administer prescription medications, the administration or medications shall be under the professional oversight of the health care
consultant. Medication prescribed for campers brought from home shall only be administered if it is from the original container,
there is written permission from the parent/guardian and the health care consultant approves in writing the administration of the
medication.
105 CMR 430.160(D) When no longer needed, medications shall be returned to a parent/guardian whenever possible. If the
medication cannot be returned, it shall be destroyed.
*Health Supervisor – A person who is at least 18 yrs. of age, specially trained and certified in first aid as well as current American
Heart Association CPR, has been trained in the administration of medications and is under the professional oversight of a licensed
health care professional authorized to administer prescription medications.
Name of Camper:

Parent or Guardian Name:
Name of Licensed Prescriber:
Name of Prescribed Medication(s):
Dosage information:

Route of Administration:
Expiration Date of Medications Received:
Special Storage Requirements:
Specific Directions (e.g., on empty stomach/with water, etc.):
Specific Precautions:
Possible Side Effects/Contraindications:
Other medications (at parent’s discretion):
I hereby authorize Discovery Adventures to administer to my child the medications specified above:
Parent/Guardian Signature:


Health Consultant Signature:

(Discovery Adventures staff)

Source: http://discoadventures.com/system/resources/BAhbBlsHOgZmSSIwMjAxMi8wMi8yMy8xMi81OC81MC8yMzYvUmVnaXN0cmF0aW9uM3BnLnBkZgY6BkVU/Registration3pg.pdf

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