17  Three  Sisters  Road,  17  Three  Sisters  Road  *  St.  James,  New  York  11780  *  631.584.5555(p)*631.862.7664(f)  

www.campharbor.org  

 

   

Camper  Nam

e  ___________________________________________  Group  ___________________________Year  ______________  

HEALTH HISTORY FORM Dates of Camp Attendance ________________________ (Required for Attendance)

TO BE COMPLETED BY A PARENT Camper’s Name _________________________________________ Last First Middle Birth Date _______________________ Age at Camp __________

Home Address _________________________________________________________________________ □ Male □ Female Street Address City State Zip

Custodial parent/guardian__________________________________________ Home Phone _________________Cell __________________

Business Address ________________________________________________________________Business Phone ______________________ Street Address City State Zip

Second parent/guardian or other emergency contact _________________________ Home Phone ______________ Cell ________________

Address ___________________________________________________________________________________________________________ Street Address (if different from above) City State Zip

Business Address ________________________________________________________________ Business Phone ______________________ Street Address City State Zip

Additional contact in event the parent/guardian cannot be reached ___________________________________________________________

Relationship to Camper _____________________________________Home Phone ____________________ Cell ______________________

Mail this form to the address below by May 1st.

Camp Harbor 17 Three Sisters Road St. James, NY 11780

Allergies: □ No known allergies.

□ This camper is allergic to: □ Food □ Medicine □ The

environment (insect stings, hay fever, asthma, etc.) □ Other

Please list all allergies and describe the reaction seen. _________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Medical Insurance Information: This camper is covered by family medical/hospital insurance. □ Yes □ No Insurance Company ______________________________ Policy Number__________________________________

Subscriber______________________________________ Insurance Company Phone Number ______________________________________________ *Please include a copy of both sides of the insurance card with this form.*

Parent/Guardian Authorization for Health Care:

This health history is correct and complete as far as I know, and the person herein described has permission to engage in all camp activities except as noted. I give permission to the camp to provide routine health care, administer prescribed medications, and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for the treatment, referral, billing, or insurance purposes. I give permission to the camp to arrange necessary related transportation for me/my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out of camp. Signature of Parent/Guardian or Adult Staffer ______________________________________________ Date: _______________________ Printed name _________________________________________ Relationship to Camper: _______________________________________

If for religious or other reason you cannot sign this, please submit a signed legal waiver for attendance.

NYS Sunscreen Permission New York State Public Health Law now requires written parental permission for a child to carry and use sunscreen at camp. The legislation further requires the camp to maintain record of the parental permission and allows camp staff to assist with the application of sunscreen when the child is unable to do so, provided the child requests the assistance and that this assistance is permitted by the parent. I hereby give permission for________________________________________ to carry and use sunscreen at camp and to use it throughout the day. If my child needs help re-applying sunscreen, I give permission for camp staff to provide my child with assistance if he/she requires it. Parent Signature Date

 17  Three  Sisters  Road,  17  Three  Sisters  Road  *  St.  James,  New  York  11780  *  631.584.5555(p)*631.862.7664(f)  

www.campharbor.org  

 

   

  Immunization History: Please provide the month, day, and year for each immunization. Copies of immunization forms from your health-care provider are also acceptable. Please attach to this form.

Immunization Dose 1 Month/Day/Year

Dose 2 Month/Day/Year

Dose 3 Month/Day/Year

Dose 4 Month/Day/Year

Dose 5 Month/Day/Year

Most Recent Dose Month/Day/Year

Diphtheria, tetanus, pertussis (DTaP) or (TdaP)

Tetanus booster (dT) or TdaP)

Mumps, measles, rubella (MMR)

Polio (IPV)

Haemophilus influenza type B (HIB )

Hepatitis B

Hepatitis A

Varicella (chicken pox)

Meningococcal meningitis (MCV4)

Pneumococcal (IPC)

Tuberculosis (TB) test Date: □ Negative □ Positive

Medications Being Taken

Please list ALL medications (including over the counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire time at camp. Keep it in the original packaging/bottle that identifies the prescribing physician (if it is a prescription drug), the name of the medication, the dosage, and the frequency of administration.

GENERAL QUESTIONS (Explain “ Yes” answers below)

Has /does the participant: Yes No Yes No 1. Had Measles, Chicken Pox, German Measles, Mumps,

Hepatitis A, Hepatitis B or Hepatitis C? 15. Ever had high blood pressure? 2. Had any recent injury, illness or infectious disease? 16. Ever been diagnosed with a heart murmur? 3. Have a chronic or recurring illness/condition? 17. Ever had back problems? 4. Ever been hospitalized? 18. Ever had problems with joints (e.g., knees, ankles)? 5. Ever had surgery? 19. Have an orthodontic appliance being brought to camp? 6. Have frequent headaches 20. Have any skin problems (e.g., itching, rash, acne)? 7. Ever had a head injury? 21. Have diabetes? 8. Ever been knocked unconscious? 22. Have asthma? 9. Wear glasses, contacts or protective eye wear? 23. Had mononucleosis in the past 12 months? 10. Ever had frequent ear infections? 24. Had problems with diarrhea/constipation? 11. Ever passed out during or after exercise? 25. Have problems with sleepwalking? 12. Ever been dizzy during or after exercise? 26. If female, have an abnormal menstrual history? 13. Ever had seizures? 27. Have a history of bed-wetting? 14. Ever had chest pain during or after exercise? 28. Ever had an eating disorder?

Please explain any “Yes” answers, noting the number of the questions. _______________________________________________________________________________ ___________________________________________________________________________________________________________________________________________

Use this space to provide any additional information about the participant’s behavior and physical, emotional or mental health about which the camp should be aware. ___________________________________________________________________________________________________________________________________________

Name of family physician ___________________________________________________________ Phone (______) ____________________________________________ Address ____________________________________________________________________________________________________________________________________ Name of family dentist/ orthodontist ___________________________________________________ Phone (______) ___________________________________________ Address ____________________________________________________________________________________________________________________________________

□ This person takes NO medications on a routine basis. OR □ This person takes medications as follows: Med #1_______________________________________ Dosage______________________ Specific times taken each day __________________________________ Reason for taking ______________________________________________________________________________________________________________________ Med #2_______________________________________ Dosage______________________ Specific times taken each day __________________________________ Reason for taking ______________________________________________________________________________________________________________________

Attach additional pages for more medications. Identify any medications taken during the school year that camper does/may not take during the summer. _________________________________________________ _______________________________________________________________________________________________________________________________________

Screening Record (For camp use only) Screened by ___________________________________________________________

Date screened ___________Time _________________am/pm Updates/additions to health history noted Yes No None required Meds received ___________________________________________________________________________________________________________________________ Current health needs identified _______________________________________________________________________________________________________________ Observational notes _______________________________________________________________________________________________________________________