Office Use Only: Last Name, First ________________________ Unit __________________________________ Session______________
Girl Scouts of Central and Western Massachusetts
2017 Camp Health Information Form
800-462-9100 (toll free in MA or 413-584-2602) / www.gscwm.org
My camper is attending the
following camp(s):
Important Information:
•
•
•
THIS FORM MUST BE FILLED OUT COMPLETELY AS REQUIRED BY LAW.
The information contained in this health form is used to advise our health care supervisor of your
camper’s current condition and special needs. It also contains information that we will use in the
case of an accident or emergency. Information on this form is confidential and will be shared with
staff only as appropriate.
This health form must be completed and signed. Campers will not be permitted to remain at camp if
this form is not provided or incomplete.
Please check all that apply.
OVERNIGHT CAMP
Camp Bonnie Brae
Camp Green Eyrie
DAY CAMP
Bonnie Brae
Camp Green Eyrie
Camp Lewis Perkins
Camp Laurel Wood
Section A: Camper Information (Required for Day and Overnight Campers)
Please list information that will be current during your campers stay. Please inform emergency contacts when your camper will be at camp
and they are an emergency contact.
Camper’s Name:
Age:
Address:
Birthdate:
City:
State:
Zip:
Home Phone:
Parent Guardian #1 Name:
Home Phone:
Work Phone:
Cell Phone:
Parent Guardian #2 Name:
Home Phone:
Work Phone:
Cell Phone:
Emergency Contact Name:
Home Phone:
Work Phone:
Cell Phone:
Camper Password:
Program(s) Camper is attending:
Please list in order.
Program Name:
Dates:
Program Name:
Dates:
Program Name:
Dates:
Program Name:
Dates:
Section B: Health History (Required for Day and Overnight Campers)
Medical Contact Information
Name of Family Physician:
Phone:
Name of Dentist/Orthodontist:
Phone:
Medical/Hospital Insurance:
Policy#/Group:
Name of Insured:
Relationship to Camper:
Allergies
Plants/Pollen
Reaction:
Treatment:
Insect Stings
Reaction:
Treatment:
Food
Reaction:
Treatment:
Drug
Reaction:
Treatment:
Other:
Reaction:
Treatment:
Office Use Only: Last Name, First ________________________ Unit __________________________________ Session______________
Immunizations - Please attach a physician’s record of immunizations.
If your child does not receive immunizations due to religious or health reasons, please provide a letter signed by the parent/guardian and
the child’s physician, to the effect that the individual is in good health and stating the reason for such objections.
Required immunizations (per MA Department of Public Health):
•
Measles, Mumps, and Rubella (MMR) Vaccine: At least one dose of MMR Vaccine must be administered at or after 12 months of
age or there must be proof of laboratory evidence of immunity. A second dose of live, measles containing vaccine is required
for all campers of any age, including those that are 5 years old and staff. Both doses of measles vaccine must be given at least
one month apart and be given at or after 12 months of age, or there must be laboratory evidence of immunity.
•
Polio Vaccine: At least three doses of either trivalent oral polio vaccine (OPV) or enhanced potency inactive polio vaccines (eIPV) are required. If a mixed schedule of polio vaccine is given (IPV or OPV), a total of 4 doses are required.
•
Diphtheria and Tetanus Toxoids and Pertussis Vaccine: At least four doses of DtaP/DTP/DT/Td are required. The pertussis
component is not given to anyone seven years of age or older. A booster dose of tetanus/diphtheria, adult type toxoid (Td) is
required if more than ten years have elapsed since last dose.
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Hepatitis B: For all children born on or after January 1, 1992, three doses of Hepatitis B are required.
General Health History Questions
Has/does participant:
1. Had any recent injury, illness, or infectious disease?
2. Have a chronic or recurring illness/condition?
3. Ever been hospitalized?
4. Ever had surgery?
5. Have frequent headaches?
6. Ever had a head injury?
7. Ever been knocked unconscious?
8. Wear glasses, contacts or protective eyewear?
9. Ever had frequent ear infections?
10. Ever passed out during or after exercise?
11. Ever been dizzy during or after exercise?
12. Ever had seizures?
13. Ever had chest pain during or after exercise?
14. Ever had high blood pressure?
15. Ever been diagnosed with a heart murmur?
Yes
No
Has/does participant:
Yes
No
16. Ever had back problems?
17. Ever had problems with joints (i.e. knees, ankles, etc.)
18. Have an orthodontic appliance being brought to camp?
19. Have any skin problems (i.e. itching, rash, acne, etc.)?
20. Have diabetes?
21. Have asthma?
22. Had mononucleosis in the past 12 months?
23. Had problems with diarrhea/constipation?
24. Had problem with sleepwalking?
25. Have an abnormal menstrual history?
26. Have a history of bed wetting?
27. Ever had an eating disorder?
28. Ever had emotional difficulties for which professional
help was sought?
Please explain any “yes” answers, noting the number of the question(s):
As-Needed Medications
The camp health center is stocked with a variety of over-the-counter medications including acetaminophen, ibuprofen, Benadryl,
Tylenol, TUMS, and throat lozenges which are administered as indicated in physician approved standing orders. Please note any
over-the-counter medications that should NOT be administered:
Additional Information
Please tell us any additional information about your camper’s behavior, or physical, emotional, or mental health which will be
useful to our camp health care and/or camp staff:
Does your camper have any needs that will require special accommodation while at camp?
___ Yes
___ No
If yes, please contact 800-462-9100 x4035 or [email protected]. Thank you.
Office Use Only: Last Name, First ________________________ Unit __________________________________ Session______________
Section C: Medical Authorization (Required for Day and Overnight Campers)
If your camper needs to have prescribed medication administered during camp hours, this section must be signed by the
prescribing physician. All medication prescribed for campers shall be kept in original containers bearing the pharmacy label, which shows
the date of filling, the pharmacy name and address, the filling pharmacist’s initials, the serial number of the prescription, the name of the
patient, the name of the prescribing practitioner, the name of the prescribed medication, directions for use and cautionary statements, if
any, contained in such prescription or required by law, and if tablets or capsules, the number in the container. All over the counter
medications for campers shall be kept in the original containers containing the original label, which shall include the directions for use. List
below any medication your camper is bringing to camp, its dosage and use. Please use an additional sheet of paper if needed.
Medication #1:
Reason for taking:
Medication #2:
Reason for taking:
Medication #3:
Reason for taking:
Prescribing Doctor’s Name:
Dose:
Time to administer:
Side effects?
Dose:
Time to administer:
Side effects?
Dose:
Time to administer:
Side effects?
Physician Signature:
Date:
Please identify any medications taken during the school year that the camper does/may not take during the summer:
Section D – Consent & Permission to Treat (Required for Day and Overnight Campers)
This health form is correct and complete so far as I know. I hereby give my permission to medical personnel selected by GSCWM and the
camp to provide routine health care, administer prescribed, and over-the-counter medications as noted, and to seek emergency medical
treatment for me or my child/ward.
In the event that 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 herein described.
I authorize the medications I have listed to be administered by GSCWM designated health care staff, as directed, to the minor/camper for
whom it was prescribed.
My child/ward has permission to engage in all prescribed camp activities except as noted:
Parent/Guardian Printed Name:
Parent/Guardian Signature:
Date:
Office Use Only: Last Name, First ________________________ Unit __________________________________ Session______________
Section E – Report of Licensed Physician (Required for Overnight Campers Only)
Some physicians’ offices provide patients with a print-out of an exam. If that’s the case, then GSCWM will accept the physician’s report
stapled to this form, providing that, at minimum, the information listed below is included on the report).
REPORT MUST BE WITHIN THE PAST 24 MONTHS AS PER STATE LAW.
Camper’s Name:
Date of Exam:
Date of Birth:
Height:
Weight:
Blood Pressure:
Pulse:
List conditions for which the patient is currently under care:
List serious accidents and injuries that have occurred during past six months:
Describe physical conditions requiring restrictions on participation in camp programs:
I hereby state, with noted exception, that this person is in apparent good health and is physically able to participate in strenuous activities
like swimming, boating, hiking and other outdoor activities.
Physician’s Signature:
Printed Name or Stamp:
Date:
Phone: