Douglascamp.com

DOUGLAS RANCH CAMPS
Please include a copy of your campers insurance card, both front & back THIS PAGE TO BE FILLED IN BY PARENTS/GUARDIANS OF CAMPER Information on this form is not part of the camper acceptance process, but is collected to assist us in identifying appropriate care.
Name ______________________________________________________ Birthdate _______________ Gender _______Age ______ Parent or Guardian’s Name(s) ___________________________________________________________________________________Home Address _______________________________________________________________________________________________ Home Phone __________________________ Business Phone _____________________ Cell Phone _________________________ Second Parent or Guardian’s Name (if not listed above) _______________________________________________________________Home Address _______________________________________________________________________________________________ Home Phone __________________________ Business Phone ______________________ Cell Phone _________________________ Business Address (include if not listed above) ______________________________________________________________________ Primary Contact: ❑ Mother ❑ Father ❑ GuardianIf the above people are unavailable in an emergency, notify (must be different than above names):Contact Name/Relationship __________________________________________________ Home Phone ______________________Address __________________________________________________________________ Business Phone ____________________ THIS BOX MUST BE COMPLETED FOR ATTENDANCE Parent/Guardian Authorizations:
This health history is correct as far as I know, and the person herein described has permission to engage in all prescribed camp activities except Participation Waiver:
We do not mean to alarm you or to suggest that summer camp activities are unsafe. However, we do want you to be informed that in addition to natural hazards, active and adventurous activities such as swimming, horseback riding, archery, riflery and other Douglas Ranch Camps activities listed and unlisted in our brochure and our website, by their nature do present a challenge as well as a risk to person and property. Douglas Ranch Camps activities take place in the outdoors, in natural and man-made environments, and contain inherent risks of serious injury including partial or full paralysis, or death. By enrolling your child(ren) in Douglas Ranch Camps, you agree to accept and assume any and all risk of such injury, death, and damages or property damage, to your child(ren) which may arise out of or in connection with your child(ren)’s participation. By enrolling your child(ren) in Douglas Ranch Camps you release, and agree to indemnify and hold harmless, Douglas Ranch Camps and all it’s officers, directors, employees, agents and representatives whatsoever from any and all losses, claims, damages, liabilities, costs and expenses (including, but not limited to, attorney’s fees) which they, or any of them, or any camper may sustain or incur in any way arising out of or in conjunction with the camper’s participation in any camp activities. Information on this form may be shared on a “need to know” basis with camp staff. I give permission to have Permission to Provide Necessary Treatment or Emergency Care:
I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests, treatment; to release any records neces- sary for insurance purposes; and to provide or arrange necessary related transportation for me/or my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for the person named above. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status. Parent/Guardian __________________________________________________Date: __________ to camper: ___________________________I also understand and agree to abide with the restrictions placed on my camp activities.
Signature of camper ___________________________________________________________________ Date: __________________________ If for religious reasons you cannot sign this please contact us for a legal waiver which must be signed for attendance.
This form is due by May 1st.
THIS PAGE TO BE FILLED IN BY PARENTS/GUARDIANS OF CAMPER HEALTH HISTORY:
The intent of this information is to provide the camp nurse/medical professionals the background to provide appropriate care. Please keep a copy of the completed form for your records. Any changes to this form should be provided to the camp nurse/doctor upon your child’s arrival at camp. Provide complete information so that Douglas Camps can be aware of your needs. All information is confiden- tial and will only be shared on a need to know basis. Attach additional pages if necessary.
ALLERGIES: ❑ No known allergies. ❑ This camper is allergic to: ❑ Food ❑ Medicine ❑ The environment (insect stings, hay fever, etc.)
(Please describe below what camper is allergic to and the reaction seen.)
DIET, NUTRITION: (please complete the “Kitchen Food Allergies” form for a camper with special food needs.)
❑ This camper eats a regular diet. ❑ This camper eats a regular vegetarian diet. ❑ This camper is lactose intolerant. (Please describe below.)
RESTRICTIONS: ❑ I have reviewed the program and activities of the camp and feel the camper can participate without restrictions.
❑ I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations. (Please describe below.)
GENERAL HEALTH HISTORY: Check “Yes” or “No” for each statement.
12. Passed our/had chest pain during exercise? . ❏ 3. Have recurrent/chronic illnesses? . ❏ 13. Had mononucleosis (“mono”) in the past 12 months? . ❏ 4. Had a recent infectious disease? . ❏ 14. If female, have problems with periods/menstruation? . ❏ 15. Have problems with falling asleep/sleepwalking?. . ❏ 6. Had asthma/wheezing/shortness of breath? . ❏ 18. Have problems with diarrhea/constipation? . ❏ 10. Wear glasses, contacts, or protective eyewear? . ❏ 20. Traveled outside the country in the past 9 months? . ❏ Please explain “Yes” answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited and
MENTAL, EMOTIONAL, and SOCIAL HEALTH: Check “Yes” or “No” for each statement.
Has the camper: 1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)? .❑ Yes ❑ No 2. Ever been treated for emotional or behavioral difficulties or an eating disorder? .❑ Yes ❑ No 3. During the past 12 months, seen a professional to address the mental/emotional health concerns? .❑ Yes ❑ No 4. Had a significant life event that continues to affect the camper’s life? .❑ Yes ❑ No (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others) Please explain “Yes” answers in the space below, noting the number of the questions. The camp may contact you for additional information.
MEDICAL INSURANCE INFORMATION:
This camper is covered by family medical/hospital insurance: ❑ Yes ❑ No Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable.
Insurance Company _______________________________ Policy Number ________________________________
Subscriber ___________________________ Insurance Company Phone Number____________________________ THIS PART TO BE FILLED IN BY PARENTS/GUARDIANS OF CAMPER DISEASE AND IMMUNIZATION HISTORY Provide the last month and year for each immunization shown. Starred (*) immunizations must
be current. Copies of immunization forms from state or local governments are acceptable; please attach to this form.
Which of the fol owing has your child had?❑ Measles _____ MMR or
Tuberculosis (TB) test: Date: _______ ❑ Negative ❑ Positive
If your camper has not been ful y immunized, please sign the following statement: I understand and accept the risks to my child from not being
fully immunized.
Parent/Guardian: ______________________________________________ Date: _____________ Relationship to Camper: _____________________
MEDICATIONS : “Medication” is any substance a person takes to maintain and/or improve their health. Please list ALL medication (including over-the-
counter or nonprescription drugs, creams and vitamins) taken routinely. Pack enough medication to last the entire time at camp. Keep it in the original pack- aging/bottle that identifies the prescribing physician (if a prescription drug), the name of the patient, the name of the medication, the dosage, and the frequency of administration. All medication will be kept and dispensed at the Health Center. Attach additional pages for more medications.
❑ This person will take NO daily medications while attending camp. ❑ This person will take the following daily medication(s) while at camp: Name of medication
Date started
Reason for taking it
When it is given
Amount or dose given
How it is given
Identify any medications taken during the school year that the participant does/may not take during the summer: __________________________ The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and
injury. Cross out those the camper should NOT be given.
Diphenhydramine antihistamine/al ergy medicine (Benadryl) Dextromethorphan cough syrup (Robitussin DM) Fiber for constipation (Metamucil wafers) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Any others? Please list below.
THIS PAGE TO BE FILLED IN BY PARENTS/GUARDIANS OF CAMPER Name of family physician ___________________________________________________Phone ___________________________Address __________________________________________________________________________________________________ Name of family dentist/orthodontist ___________________________________________Phone ___________________________ Address __________________________________________________________________________________________________ CONFIDENTIAL INFORMATION
We are committed to providing a wonderful experience for your child this summer and we encourage you to make us a full
partner in ensuring that this will be a summer of fun and accomplishment for them.
Our enrollment form does not contain enough space for you to share personal information about your child, his/her personality or recent experiences. We try to talk with all of our Douglas Camp families in person before the summer starts in order to answer all of your questions and to ensure confidence that your child will have a happy and safe summer at our camp. However, we realize that it is sometimes difficult to relay important information while in the middle of a group or on the first day of camp when you are saying good-bye to your child, so completing this form along with the Letter to My Counselor and Camper Profile helps us prepare.
What Have We Forgotten to Ask? Please provide in the space below any additional information abou the camper’s health that you think
important of that may affecct the camper’s ability to ful y participate in the camp program. Attach additional information if needed.
THIS PART TO BE FILLED IN BY LICENSED MEDICAL PERSONNEL Health Care Recommendations by Licensed Medical Personnel (seen within the last 24 months)
I have examined this camp applicant. Date of Last Examination __________________________________________________________________
Height ____________________________ Weight ___________________________________Blood Pressure ______________________________
In my opinion, this applicant ❑ is ❑ is not able to participate in an active camp program.
The applicant is under the care of a physician for the following conditions ____________________________________________________________ Current treatment at the time of this report includes _____________________________________________________________________________
_______________________________________________________________________________________________________________________
Recommendations and Restrictions at Camp
Treatment to be continued at camp ___________________________________________________________________________________________
Medications to be administered at camp (name, dosage, frequency) _________________________________________________________________
Any medical y-prescribed meal plan or dietary restrictions ________________________________________________________________________
Known allergies/reactions (food, drugs, plants, insects, etc.) _______________________________________________________________________
Description of any limitation or restriction on camp activities ______________________________________________________________________
Additional information for health care staff at the camp __________________________________________________________________________
_______________________________________________________________________________________________________________________
Signature of Licensed Medical Personnel _____________________________________________________ Date ___________________________Printed ________________________________________________________________________________ Title ___________________________Address _______________________________________________________________________________ Phone __________________________ douglas ranch camps
33200 E. Carmel Valley Road, Carmel Valley, CA 93924

Source: http://www.douglascamp.com/images/file/Parent%20Packets/Parent_Packet_09/Health_Form.pdf