Microsoft word - 2014health history form for res camp.doc
Girl Scouts of NE KS & NW MO 8383 Blue Parkway, KC, MO 64133
816-358-8750 Fax 816-358-5714 www.girlscoutsksmo.org
Health History Form for Resident Camp
Must be completed annually by parent or guardian and filed within 2 months of camp.
The information on this form is gathered to assist us in identifying appropriate care for your daughter during her camp session.
Keep a copy of the completed form for your records. Any changes to this form should be provided upon participant’s arrival. Please provide complete information so that health personnel can be aware of your daughter’s needs.
Health History Please type or write clearly and legibly. Date of Birth: (XX/XX/XXXX) Address: Alternate Phone: Age at camp: Camper lives with this person Yes Relationship: Day Phone: Evening Phone/Cell Phone: Camper lives with this person Yes Relationship: Day Phone: Evening Phone/Cell Phone: Emergency Contact: Relationship: Alternate Phone: Check all that apply and explain in detail checked answers: Physical restrictions Asthma or Hayfever Diabetes
¨ Recent injury, illness or infectious disease
¨ Skin problems (itching, rash, acne, etc.)
¨ Diseases of the Ears or Ear Infections
¨ Eating Disorders (Anorexia, Bulimia, etc.)
¨ Emotional difficulties requiring professional help
¨ Had surgery or hospitalized in the last 5 years
Please explain in detail all checked answers marked above (for diabetes or asthma, attach a sheet explaining treatment in detail. For asthma, include frequency of attacks, triggers, action plan, peak flows, etc.):
Participant Name: _________ Allergies: Please list all allergies, the type of reaction and its severity, treatment and date of last reaction. Include allergies to medications, food, insects, animals, plants, etc. Allergies Reaction/ Severity Treatment Date of last Reaction
Does the camper suffer from Anaphylaxis?
*Anaphylaxis is a severe allergic reaction marked by swelling of the throat or tongue, hives, and trouble breathing.
Medical Conditions (including any precautions or restrictions on activities) Name of Condition Precautions/Restrictions
Medications: List any medications currently taken (or has taken in the recent past) including dosage schedule and specific instructions for use. Medication Dosage Schedule Specific Instructions
Over-the-Counter Medications: In case of accident or injury, the following over-the-counter medications are kept on –hand in the camp health center. Please check all that your camper may take if needed:
Special considerations or notes about over-
If not, has she been told about it? Yes No
If your daughter will be menstruating while she is at camp, she must use tampons if she wishes to swim. Some families prefer to have their camper sit out of swimming activities.
My daughter is permitted to use tampons My daughter should abstain from swimming while menstruating
Is there a Special Medical or Dietary Regiment to be followed? ____________________________________________________________________________________________________ ____________________________________________________________________________________________________
Additional information that is important for us to know about: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Participant Name: _________ Record of Immunization Which of the following has the camper had? Health Insurance Information Policy Holder's Name Policy Number Insurance Company Name Group Number (Girl Scout insurance will cover usual and reasonable charges for sickness and accident treatment during camp but does not eliminate the need for individual insurance. The Girl Scout Council is not responsible for providing full insurance coverage. It is necessary for you to provide insurance. Please contact your provider to check on your coverage.)
Name of family physician:_________________________________
Name of family dentist/orthodontist:_________________________
Phone (____)______________________________ The person herein named has permission to engage in all activities, including trips beyond the primary program location related to the program,
except as noted. I have read the program information provided and understand and agree to comply with all procedures.
This health history is correct and complete as far as I know. I hereby give permission to the Girl Scouts to provide, seek, and consent to routine health care, administration of prescribed medications and emergency treatment for my child, as may be necessary, including, but not limited to x- rays, routine tests and treatment, and/or hospitalization. I also give permission for the Girl Scouts to arrange related transportation. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes.
It is my intention that the Girl Scouts be treated as acting in loco parentis if the person herein named is a minor. Further, it is my intention that
the appropriate representatives of the Girl Scouts be treated as “personal representatives” for the purposes of disclosing protected health information pursuant to the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996. I hereby agree (pursuant to 45 CFR § 164.510 (b)) to the disclosure to camp representatives of the protected health information of the person herein
described as necessary: (i) to provide relevant information to the Girl Scout representatives related to the person’s ability to participate in
activities; and (ii) in the case of minors, to provide relevant information to the Girl Scout representatives to keep me informed of my child’s health
status. I authorize any hospital, physician, medical practitioner, clinic, or other related facility to furnish to Mutual of Omaha Insurance Company, or anyone acting on its behalf, all information concerning medical, dental and hospital records for my child, to be used for the purpose of evaluating claims for benefits. I have the right to receive a copy of this authorization upon request. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Girl Scouts to secure and administer
treatment, including hospitalization and/or injection and/or anesthesia and/or surgery for the person named above. This completed form may be
photocopied for trips beyond the primary program location. Photographs taken of my daughter may be used by Girl Scouts of NE KS & NW MO, Inc., its assigns or successors, in whatever way they may
desire including television and the World Wide Web. Furthermore, I consent that such photographs and plates from which they are made shall
be their property and they have the right to sell, duplicate, reproduce, in the form of advertising or otherwise publish, and make other uses of
such photographs and plates as they may desire, free and clear of any claim whatsoever on my part.
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CURRICULUM VITAE ADDRESS : Office of Continuing Medical Education Danville Regional Medical Center 142 South Main Street Danville, Virginia 24541 Telephone: (434) 799-2178 E-mail: firstname.lastname@example.org PERSONAL INFORMATION : EDUCATION : University of North Carolina at Chapel Hill Chapel Hill, North Carolina BA (Chemistry) University of North Carolina School of Medicine Chapel