Camp McDowell Camper Health Form (general) 105 Delong Rd Nauvoo, AL 35578 www.campmcdowell.com Phone: 205.387.1806 Fax: 205.221.3454 Camp Session: _______________________________ Session start date: __________ Session End date: ___________ Updated October 2015 ​Page 1 All information is confidential­PLEASE PRINT NOTE: Bethany’s Kids campers with physical challenges or learning differences: please complete the Camp McDowell Health form for Bethany’s Kids with space provided for information on ADLs. All others, complete this Camper Health Form (general). CAMPER NAME​_____________________________________________________________________________________________________________________________ (LAST) (FIRST) (MIDDLE) (PREFERRED NAME) CAMPER INFORMATION: ​Date of Birth: ____________ Sex: M / F Age _______ Grade: ____________ Height & Weight: __________________ Primary Physician ________________________________________ Physician Phone ___________________________ CONTACT INFORMATION: Primary Parent / Guardian Name ____________________________________________________________________________________________________________________ Address________________________________________________________________________________________________________________________________________ (STREET)
(CITY) (STATE) (ZIPCODE) Phone__________________________________________________________________________________________________________________________________________ INCLUDE AREA CODE ​Primary Number (ex. Home) Secondary Phone Number (ex. Cell) Alternate Phone Number (ex. Work) Email address:​ ______________________________________________________________________________________________________________________ EMERGENCY, CONTACT (if primary parent cannot be reached):​____________________________________________________________________________ (NAME & Relationship to Camper) (Day Phone) (Evening Phone) Is camper on a special diet? Y / N Please explain, ( what they CAN eat as well as what they CANNOT eat):​ ______________________________ _________________________________________________________________________________________________________________________________________________________ ***IF SPECIAL FOODS MUST BE SENT TO CAMP WITH YOUR CHILD, PLEASE CONTACT THE PROGRAM DIRECTOR*** ALLERGY INFORMATION ​ ​(attach additional sheets if necessary) ● To the best of your knowledge does your child have any allergies? ​YES / NO ● If ​YES​, please indicate to which of the following your child is allergic & what symptoms may present. Please be specific: FOODS/PLANTS/ANIMALS/INSECTS/MEDICATIONS:_________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________ ● List treatment child should receive if exposed to any of these allergens. Medicines to which your child is allergic will NOT be given​: ___________________________________________________________________________________________________ *** IF YOUR CHILD IS BRINGING AN EPI­PEN TO CAMP, YOU MUST TALK WITH OUR MEDICAL STAFF PRIOR TO ARRIVAL*** ➔ For Programs on Clear Creek (“down the hill”) Camp Contact: [email protected] or 205 387 1806 ➔ For Programs in Bethany Village (“up the hill”) Contact: [email protected] or 205 387 1806 REGARDING MEDICATIONS WHILE AT CAMP MCDOWELL​ ​GENERAL RULES: ●
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All MEDICATIONS MUST BE IN THE ORIGINAL CONTAINER​ with the camper’s name and cabin written on the container. There ​must ​be clear directions on when &/or why to give the medication.
NOTE: Give as directed is NOT acceptable The container ​must ​specify the strength and dose of the medication. If it is an Over­The­Counter medication ​it MUST be age­appropriate ​and ​will be given following manufacturer recommendations. If it is not recommended for your child’s age ​and​ your child’s healthcare provider prescribed it then a note from that provider must be sent with the OTC medication. Camper Name:​ ​ Updated October 2015­​Page 2 PRESCRIPTION MEDICATIONS: ● The following section must be filled out by the student’s PARENT or LEGAL GUARDIAN. ● ALL MEDICATION IS ADMINISTERED BY A LICENSED NURSE or EMT ● List ​ALL PRESCRIPTION MEDICATIONS ​you will send with your child and circle the best time(s) to administer this medicine to the child, choosing from the following: B*​= Before Breakfast, ​B​= After Breakfast, ​L​= After Lunch, ​C​=Canteen (3:30), ​D​= After Dinner, ​HS​= At Bedtime (Attach additional sheet if necessary)
(PLEASE CIRCLE) Medication_____________________________ Dosage________________ Reason___________________ Time Given­ ​B* B L C​ ​D HS Medication_____________________________ Dosage________________ Reason___________________ Time Given­ ​B* B L C D HS Medication_____________________________ Dosage________________ Reason___________________ Time Given­ ​B* B L C D HS OVER THE COUNTER (OTC) MEDICATIONS: ● ALL OTC MEDICATIONS MUST BE PROVIDED BY PARENTS/LEGAL GUARDIANS OF THE STUDENT ** ● Please list the OTC medicines that you will be sending with your child on the lines provided below: Name of OTC Medication Reason(s) for Giving & Time
(EXAMPLE) CLARITIN (EXAMPLE) SEASONAL ALLERGIES EVERY DAY BEFORE BREAKFAST ________________________________________________
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● In the event of unexpected illnesses, limited OTC medicines will be available for your child. Which of the following medicines do you permit to be given to your child by our Nurse or EMT?
Ibuprofen: Yes__ No__ Acetaminophen: Yes__ No__ Benadryl: Yes__ No__ Cough Drops: Yes__ No__ Tums: Yes__ No__ LIST ADDITIONAL PERTINENT PHYSICAL, EMOTIONAL, or MENTAL HEALTH INFORMATION and/or MEDICAL HISTORY YOU WISH TO PROVIDE (attach additional sheets if needed) ______________________________________________________________________________________________________________
______________________________________________________________________________________________________________ ACCIDENT INSURANCE COVERAGE​ Accident insurance costs are covered in the program fee and protect all students throughout the program. The maximum benefits are: Sickness, $1000; Accidents, $2500; and Loss of Life, $2500. Parents or guardians are responsible for expenses in excess of these amounts. MEDICAL AUTHORIZATION AND RELEASE
“I AUTHORIZE THE NURSE, EMT, OR AUTHORIZED CAMP PERSONNEL, THE TASK OF ASSISTING MY CHILD IN TAKING THE ABOVE MEDICATIONS. I GIVE THE NURSE/EMT PERMISSION TO SPEAK WITH MY CHILD’S HEALTH CARE PROVIDER OR PHARMACIST AND AUTHORIZE MY CHILD’S HEALTHCARE PROVIDER OR PHARMACIST TO SPEAK WITH THE NURSE/EMT SHOULD A QUESTION COME UP ABOUT ONE OF MY CHILD’S MEDICATIONS. ALL HEALTH INFORMATION IS CONSIDERED CONFIDENTIAL AND WILL BE SHARED ONLY ON A NEED­TO­KNOW BASIS TO ENSURE THE SAFETY OF YOUR CHILD.” ​"This is to certify that the information provided on this form is accurate to the best of my knowledge," DESCRIPTION OF ESSENTIAL FUNCTIONS OF A CAMPER: With the exception of Bethany’s Kids campers, ​in order to participate in our summer camp programs, a child should be able to meet their personal needs, move independently from place to place, and cooperatively function in a group setting. Our professional staff is not trained to give individualized attention to children with special needs beyond these parameters (with the exception of Bethany’s Kids). Camp McDowell also offers sessions particularly designed for inclusion of campers with physical disabilities and intellectual differences: Special Session(for adults) and Bethany’s Kids (for youth with special needs and typical kids). For Bethany’s Kids and other sessions in Bethany Village (“up the hill”), please contact Susanna Whitsett at [email protected]. For Special Session, please contact Lindsey Mullen at [email protected]. For Summer Camps on Clear Creek (“down the hill”), contact Stratt Byars at [email protected] or 205.387.1806. Information on all camps may be found at www.campmcdowell.com.