Tizmoret Shoshana 2018 Health Form

Tizmoret Shoshana 2018 Health Form

Important Note: In accordance with HIPAA guidelines, the Senior administrative staff and Nurse of Camp Tizmoret Shoshana will hold all information contained in this form in the strictest of confidence, only sharing information, if necessary, with licensed healthcare professionals.

A COPY OF EACH CAMPER’S CURRENT HEALTH INSURANCE CARD MUST ACCOMPANY THIS FORM. Thank you.

Name: ______

Parents’/guardians’ names:______

Birthday: ______Age (as of June 21, 2018):______

Emergency contact numbers, including area code (please include at least one emergency contact who is not a camper parent):

Name: Home Phone: Cell Phone: Work Phone: Relationship:

______

______

______

Name and Phone number (including area code) of pediatrician or family physician:

______

Allergies (check and specify all that apply)

__ Bee Sting

__ Peanuts

__ Food ______

__ Medications______

__ Other______

Do any allergies require anEPI-PEN injection? No__ Yes__

Date of last tetanus booster: ______

Health conditions (check and detail all that apply)

__Asthma __Colitis

__Diabetes __Epilepsy/seizure disorder

__Hearing impairment __Heart disorder

__Kidney disease __Psychiatric

__Skincondition __Thyroid disorder

__Other __Ulcers

__Visual impairment __ Clotting disorder/Hemophilia

Please provide details of any condition checked off: ______

______

Any history of:

Dizziness, lightheadedness, or fainting associated with exercise? No____Yes___

Irregular heartbeat or heart rhythm disorder No__Yes__

Has a physician ever denied or limited activity for any health reasons? No__ Yes__

Any limitations or restrictions of camp activities? No__Yes__

______

Any physical or emotional conditions we need to be aware of that may affect your daughter’s participation in this program? No___ Yes___ (Please specify and include circumstances when a physician should be notified.)

______

Has your child been treated for mental health and/or counseling in the past 3 years? No___Yes___

It is a camp policy to secure consent for medication distribution and for use of medical devices. The medications or medical device may be self- administered (by girls over age 14) or be administered by camp staff.

Medications/Medical devises participant will be taking/using during camp:

Name Reason Dosage Time of day taken/used

______

______

Do any medications require refrigeration? No__ Yes__ Please specify.______

Prescribing physicians name and phone number, including area code:

______

Are there any side effectsfrom medication such as mood/behavior changes, sleepiness, or upset stomach? No__ Yes__ (please specify)

______

__ My daughter is not bringing any medication/medical devices to camp

__ (for girls over age 14 only) My daughter will self-administer medication(s) and use medical devices on her own.

__ Staff should administer medication (please provide any special instructions for administering medication)

Name of health insurance company:______

Name of policy holder:______Policy number: ______

I give consent inadvance for medical treatment at an appropriate medical facility in case of illness or injury.

I give consent in advance for staff member(s) of Tizmoret Shoshana to contact my daughter’s physician(s). I also give consent in advance for my daughter’s physician to share medical information with Tizmoret Shoshana staff and/or health-care providers.

I agree to hold harmless and indemnify TizmoretShoshana, its officers, agents and employees from any and all liability, loss, damages, cost or expenses which are sustained, incurred, acquired or arising out of the activities of my daughter or ward in the course of the camp and its activities.

Camper’s name (please print):______

Signature of parent/guardian:______

Date:______

Physician’s signature:______Date:______