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Microsoft word - health form 08

Berkshire Humane Society ~ 214 Barker Road, Pittsfield, MA 01201 ~Camp Humane - 2009 Health Form
THIS SIDE TO BE FILLED OUT and SIGNED BY PARENT/GUARDIAN BACK SIDE TO BE FILLED OUT and SIGNED BY A PHYSICAN This form MUST be received by the first day of camp or the child CANNOT attend camp.

Child’s Name_________________________ Date of Birth ___________ Age_____

Parent/Guardian____________________________________________________
Address____________________________________Email__________________
City____________________ State______ Zip_________
Home Phone_______________________ Work/Cell _______________________
Child’s health history (check illness child has had, with approximate dates):
Frequent ear infections _______ Chicken Pox _______
Allergies:
Heart defect/disease _________ Measles ___________
Pet dander _____________
Convulsions _______________ Rubella ___________
Food _________________
Diabetes __________________ Mumps___________
Insect Stings ___________
Bleeding/clotting Disorder_____ Mononucleosis______
Hay Fever _____________
Hypertension_______________ Asthma___________
Penicillin _____________
____________

Operations or serious injuries (specify dates):______________________________
______________________________________________________________________________

Disability or chronic recurring illness:___________________________________
Taking any medications Y/N ______________________________
Will they be taken during the camp program Y/N Instructions___________________
Any specific activities to be encouraged or limited by physician’s advice:
________________________________________________________________
_______________________________________________________________________________
Dietary Modifications:_____________________________________________________
Food allergies or
intolerances:_______________________________________________________
Name of
Physician:______________________________Phone:_____________________
Date of last physical exam:________ Medical insurance carrier:_________________
This health history is correct so far as I know, and the child described has permission to engage in all program activities
except as noted above. Emergency authorization: I hereby give permission to the medical personnel selected by the
Program Director to order x-rays, routine tests and treatment for my child, and in the event I cannot be reached in an
emergency, I give permission to the physician selected by the program director to hospitalize, secure proper treatment
for, and to order injection and/or anesthesia and/or surgery for my child as named above. Parent/Guardian
Signature: ____________________________________
 
 
 
 
THIS SIDE MUST BE COMPLETED AND SIGNED BY PHYSICIAN 
Please record date of basic immunization and most recent booster: 
 
Vaccine 
Date of basic immunization 
Date of Booster 
_______       or_______________________________________________________________________________________________________ Tetanus Diphtheria  __________or________________________________________________________________________________________________________ Tetanus    _________________________________________________________________________________________________________   Oral Polio (Sabin) TOPV    _________________________________________________________________      ______________ _______________________________________________________  Measles_______________________________________________________       Mumps _____________________________________________________________  Rubella (German measles) __________________________________     Other ________________________________________________________________  Tuberculin test given  _______________________________________________________________________________________________________________________ 
 
Health examination by licensed physician: 
 
I have examined camp program applicant: ____________________________________________________ Date_____________________ 
 
                        child’s name  The child’s health does  __________   does not ___________      preclude participation in an active camp program. 
 
The child is under the care of a physician for the following condition(s) _______________________________________________________________ 
 
_________________________________________________________________________________________________________________________________________________ 
 
Current treatment (including current medications)_____________________________________________________ 
 
____________________________________________________________________________________________ 
 
Does child have a seizure disorder?________________________   Diabetes?_____________________________ 
 
Recommendations and restrictions while at Camp Program: 
 
Any treatment to be continued at camp program: _____________________________________________________________________________________ 
 
Any medication to be administered at program (specify drug and dosage): _________________________________________________________ 
 
______________________________________________________________________________________________________________________________________________ 
 
Any dietary restrictions: __________________________________________________________________________________________________________________ 
 
Any allergies (food, drugs, plants, insects, animals, etc) ________________________________________________________________________________ 
 
Physician’s signature______________________________________________________________________________________Date___________________________ 
 
Physician’s name: ______________________________________________________________________________________Phone #__________________________ 
 
 
Please Note:   An actual copy of the patient’s immunization records or check up evaluation can be used instead of this page.   
                            The Berkshire Humane Society does not accept camper health records through the internet. 

Source: http://briancabral.name/berkshirehumane.org/wp-content/uploads/2009/01/health_form_09.pdf