Dates of Camp Attendance

Mail this form to:

The Ranch Lake Placid Academy
P.O. Box 128
Lake Clear, NY 12945
518-891-5684

The information on this form is not part of the camper or staff acceptance process, but is gathered to assist us in identifying appropriate care. Health history (first three pages) must be filled out by parents/guardians of minors or by adults themselves. Update required annually. Health exam (back page) must be completed by approved licensed medical personnel at least every two years.

GENERAL INFORMATION

Name Birth date Age at camp

Last

First

Middle

Home address

Social security number of participant Gender: Male Female

Custodial parent/guardian Phone

Home address

(if different from above)

Street  address

City

State

Zip

Business address Phone

Street  address

City

State

Zip

Second parent or guardian or emergency contact

Address Phone

Street  address

City

State

Zip

Business address Phone

Street  address

City

State

Zip

If not available in an emergency, notify:

Name

Relationship Phone

Address

Street  address

City

State

Zip

INSURANCE INFORMATION

Is the participant covered by family medical/hospital insurance? Yes   No

If so, indicate carrier or plan name Group #

Photocopy of front and back of health insurance card must be attached to this form.

Important - These boxes must be complete for attendance*

Parent/Guardian Authorizations: This health history is correct and complete as far as I know. The person herein described has permission to engage in all camp activities except as noted. I hereby 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 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 complete form may be photocopied for trips out of camp. Signature of parent/guardian or adult camper/staffer____________________________________________________ Print Name Date

I also understand and agree to abide by any restriction placed on my participation in camp activities. Signature of minor or adult camper/staffer_____________________________________ Date _____________

HEALTH HISTORY

The following information must be filled in by the parent/guardian, or adult camper or staff member. The intent of this information is to provide camp health care personnel the background to provide appropriate care. Keep a copy of the completed form for your records. Any changes to this form should be provided to camp health personnel upon participant's arrival in camp. Provide complete information so that the camp can be aware of your needs.

ALLERGIES: List all known

Medication allergies (list)	Describe reaction and management of the reaction.
Food allergies (list)
Other allergies (list) - include insect stings, hay fever, asthma, animal dander, etc.

MEDICATIONS BEING TAKEN

Please list ALL medications (including over-the-counter or non-prescription 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 a prescription drug), the name of the medication, the dosage, and the frequency of administration.

This person takes NO medications on a routine basis.

This person takes medications as follow:

Med #1 Dosage Specific times taken each day
Reason for taking

Med #1 Dosage Specific times taken each day
Reason for taking

Med #3 Dosage Specific times taken each day
Reason for taking

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

RESTRICTIONS

The following restrictions apply to this individual:

Dietary

GENERAL QUESTIONS

(Explain "yes" answers below.) Has/does the participant:

Yes	No		Yes	No
		1. Had any recent injury, illness or infections diseases?			13. Ever been diagnosed with a heart murmur?
		2. Have a chronic or recurring illness/condition?			16. Ever had back problems?
		3. Ever been hospitalized?			17. Ever had problems with joints (e.g. knees, ankles)?
		4. Ever had surgery?			18. Have an orthodontic appliance being brought to camp?
		5. Have frequent headaches?			19. Have any skin problems (e.g., itching, rash acne)?
		6. Ever had a head injury?			20. Have diabetes?
		7. Ever been knocked unconscious?			21. Have asthma?
		8. Wear glasses, contacts or protective eye wear?			22. Had mononucleosis in the past 12 months?
		9. Ever had frequent ear infections?			23. Had problems with diarrhea/constipation?
		10. Ever passed out during or after exercise?			24. Have problems with sleepwalking?
		11. Ever been dizzy during exercise?			25. If female, have an abnormal menstrual history?
		12. Ever had seizures?			26. Have a history of bed-wetting?
		13.Ever had chest pain during or after exercise?			27. Ever had an eating disorder?
		14. Ever had high blood pressure?			28. Ever had emotional difficulties for which professional help was sought?

Please explain any "yes" answers, noting the number of the questions.

Which of the following has the participant had? Measles Chicken pox German measles Mumps Hepatitis A Hepatitis B Hepatitis C TB Mantoux Test Date of last test Result: Positive Negative

Please give all dates of immunization for: Vaccine: Dates: Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr DTP TD (tetanus/diphtheria) Tetanus Polio MMR    or Measles    or Mumps    or Rubella Haemophilus influenza B Hepatitis B Varicella (chicken pox)

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

Health Care Recommendations by Licensed Medical Personnel

I examined this individual on ______________. (ACA accreditation requirements specify exams within 24 months of camp attendance. Individual camps may require annual exams. A new exam in not necessarily required for camp attendance.)

BP ___________________ Weight _____________ Height _______________

In my opinion, the above applicant is is not able to participate in an active camp program.

The applicant is under the care of a physician for the following conditions

Recommendations and Restrictions at Camp

Treatment to be continued at camp

Medications to be administered at camp (name, dosage, frequency)

Any medically-prescribed meal plan or dietary restrictions

Known allergies

Description of any limitation or restriction on camp activities

Additional information for health care staff at the camp

Signature Of Licensed Medical Personnel Printed  Title Address Phone Date

For camp use only

Screening Record Date screened ______________________________________________ Time __________________________ Meds received _____________________________________________________________________________  _________________________________________________________________________________________ Observation notes _________________________________________________________________________  _________________________________________________________________________________________ Screened by_______________________________________________