Camp Celiac Health Form

CHRONIC HEALTH CONDITIONS (Please check box AND explain below)

Asthma or other lung problem *
Bleeding/clotting disorder 
 *
Blood disorder (other type) *
Diabetes *
Ear Infections
 *
Gastrointestinal disorder (other than celiac)
 *
Heart defects
 *
Kidney disease
 *
Muscular or skeletal disorder
 *
Sleeping disorder or disturbance
 *
Seizures
 *
Any prior surgical operations
 *
Any restrictions (swimming, sports, etc.) (SPECIFY BELOW)
 *

ALLERGIES

Specify TYPE of Reaction
Medications *
Nuts *
Insect Stings *
Animals
Hayfever

IMMUNIZATIONS (Year of Last Booster)

Consent for Emergency Medical Treatment

Consent For Emergency Medical Treatment

I confirm this health history is complete and accurate. I know of no reason(s), other than the information noted on this form, why my child/I should not participate in camp activities.  I confirm I am the legal guardian of the minor listed above or I am the adult listed above.  Entering my name into the space below authorizes the officers, group leaders, or agents of Camp Celiac/Camp Arroyo to obtain and administer first aid and/or to consent to medical, surgical, dental and related treatment as might be required for the immediate care of the camper/adult listed above in the event of an emergency and for ongoing care of chronic health conditions.  I provide additional permission for the administration of non-prescription medications (such as antihistamines, acetaminophen, ibuprofen, etc.) or prescription medications, if needed, unless otherwise noted on the form under “health conditions”.

 

MEDICATIONS

Adults and campers will need to bring all essential medicines with them to check-in.  To minimize disruption to the camp schedule, we request that non-essential substances (e.g. vitamins and herbal supplements) be kept at home.  We require that all essential medications be pre-sorted into a seven-day pill sorter in advance, along with a printed schedule of when the medications should be taken. All essential medications (including over-the-counter medications) will be handed to the medical staff at check-in, stored in the infirmary and distributed at the required schedule.  Our medical facility is also stocked with over the counter medicines that may be needed for minor colds and aches.

List below the name(s) of any essential medications needed on a regular or occasional basis, and check the approximate time(s) when taken. For example, if a medication is taken ONLY in the morning, check ONLY the "morning" box for that medication.