Camper Health To Parent(s)/Guardian(s): Complete this section and give this form (FORM 2) and a copy of your completed CAMPER HEALTH HISTORY FORM (Form 1) to your child’s health-care provider for review. History Form 2
Dates will attend camp: From ______________________________ to ____________________________
Camper Name _________________________________________________________________________
Mail this form to the address below at least three weeks prior to your
Birth Date _______/_______/__________ Age on arrival at camp _________years /________months
Camper home address: _________________________________________________________________
Skyland Camp for Girls P.O. Box 128
_____________________________________________________________________________________
Clyde, NC 28721 Fax: 888-298-5711
Custodial parent(s)/guardian(s) phone: (________) _________________ (________) ________________
____________________________________________________________
Questions? Parents/Guardians: STOP here. The rest of this form is completed by medical personnel Medical Personnel: Please review the CAMPER HEALTH HISTORY FORM (Form 1) and complete all remaining sections of this form (Form 2). Attach additional information if needed.
used on and as needed basis to manage illness and injury.
Medical personnel: Cross out
No (If “no,” date of last physical ______/________/___________
those items the camper should
(Requirements specify a physical exam within 12 months prior to arriving at camp)
NOT be given:
Ibuprofen (Advil, Motrin) Phenylephrine (Sudafed PE)
Allergies:
To foods (list):
To medications: (list):
To the environment (insect stings, hay fever, etc.– list):
Other allergies: (list): Describe previous reactions:
Laxatives for constipation (Ex-Lax) Hydrocortisone 1% cream Topical antibiotic cream Calamine lotion Aloe
Diet/Nutrition:
Has a medically prescribed meal plan or dietary restrictions (describe below/on separate sheet) Current Treatment(s): The camper is undergoing treatment at this time for the following conditions: (describe below) Medication:
Will take the following prescribed medication(s) while at camp: (describe name, dose, frequency) Other treatment/therapies to be continued at camp(describe below/on separate sheet)
Do you feel that the camper will require limitations or restrictions to camp activity while at camp?
(If you answered YES, what do you recommend? (Describe below/on separate sheet) “I have reviewed the CAMPER HEALTH HISTORY FORM (FORM 1), and have discussed the camp program with the camper’s parent(s)/ guardian(s). It is my opinion that the camper is physically and emotionally fit to participate in an active camp program (except as noted above.)”
Name of licensed provider: ________________________________________ Signature: ___________________________________Title: _____________
Office Address________________________________________________________________________________________________________________ __
Skyland Camp for Girls - Rev. 12/2013 Page 1/1
Consent for use of metformin in the preconceptual, and post-conception period. Metformin , also known as glucophage , is a medication used alone or in combination with other medications to treat adults whose diabetes does not requireinsulin. It is thought to act by improving insulin binding thereby making the insulin thatis available more effective and reducing the level of insulin that i
Hatha Yoga Pradipika Chapter I On âsanas. 1. Salutation to Âdinâtha (Siva) who expounded the knowledge of Hatha Yoga, which like a staircase leads the aspirant to the high pinnacled Râja Yoga. 2. Yogin Swâtmârâma, after saluting his Gurû Srinâtha explains Hatha Yoga for the attainment of Râja Yoga. 3. Owing to the darkness arising from the multiplicity of opinions people are u
Camper Health To Parent(s)/Guardian(s): Complete this section and give this form (FORM 2) and a copy of your