PDF FORM - Girl Scouts of Greater Iowa

HEALTH HISTORY FORM
Resident Camp Form 2013
MAIL TO CAMP OFFICE
Camp Attending:
Joy Hollow
Camp Sacajawea
Camp Tanglefoot
Camper Name (first, middle, last):
(For Camp Use) Program/Unit:
(For Camp Use) Session Dates:
(This section of the Health History and Exam form to be filled out by a parent/guardian of camper/minor)
Camper’s Name: Sex: F M Age: Birth Date:
Camper’s Home Address:
Street Address, City, State, Zip Code
Parent/Guardian with legal custody to be contacted in case of an illness or injury:
Relationship
Name:
to Camper:
Home Address:
(if different than above)
Street Address, City, State, Zip Code
Cell
Phone:
Second Parent/Guardian or other emergency contact:
Name:
Name:
Allergies:
No known allergies
Relationship to
Camper:
Relationship to
Camper:
Cell
Phone:
Cell
Phone:
This camper is allergic to: food medicine the environment (insect stings, hay fever) other
(Please describe the allergy, the reaction and the treatment/medication)
Diet and
Nutrition: This camper eats a regular diet. a regular vegetarian diet. a gluten free diet. has special food needs.
Describe any special food needs:
Medical Insurance Information:
This camper is covered by family /medical /hospital insurance Yes No
Include a copy of your insurance card; copy both sides of the card so information is readable.
Insurance Company
Subscriber
Policy Number
Insurance Co. Phone Number
Important – This section must be completed for attendance
Parent/Guardian Authorization for Health Care and Release of Liability
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp
activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment
related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to
hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I further give my permission to the camp administration to select
physicians or staff to provide routine care for my child, including dispensing medications and providing first aid. I understand the information on this form will be shared on
a “need to know” basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child’s health record from
providers who treat my child and these providers may talk with the program’s staff about my child’s health status. The undersigned further agrees to defend, indemnify and
hold the Girl Scouts of Greater Iowa and its agents, servants, officers, directors and employees from any and all claims of every kind or nature and from all suits, actions or
proceedings which may be asserted or brought by or on behalf of any individual or entity. This provision shall bind and inure to the benefit of the representatives,
successors and assigns of the parties hereto. I have read this form (or have had it read to me) and I certify that I understand its contents. I give permission for my daughter to
be photographed and for the photo(s) to be used to promote council activities, or by other youth serving agencies for publication. She may participate in out-of-camp travel when
it is a part of the camp program. My daughter has permission to become a registered member of Girl Scouts of the U.S.A and her participating local Council. I give permission
for Girl Scouts Greater Iowa and/or Girl Scouts of the USA to use any photographs, video, or audio tapes taken of my daughter in camp activities for Girl Scout public
relations.
Signature of Custodial
Parent/Guardian or camper
if over the age of 18
Girl Scouts of Greater Iowa
Date
Relationship
to Camper
Resident Camp Form – Health History Form

Camper Name
The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and
injury. Cross out those the camper should not be given.
Acetaminophen (Tylenol) Hydrocortisone cream Loperamide (Imodium)
Ibuprofen (Advil, Motrin) Benadryl Cream Polyethylene Glycol (Miralax)
Antibiotic cream Calamine lotion Diphenhydramine antihistamine (Benadryl)
Burn Cream Lice shampoo or cream (Nix or Elimite) Dextromethorphan cough syrup (Robitussin DM)
Tums
General Health History: (Check “yes” or “no” for each statement)
1. Ever been hospitalized? Yes No 12. Had fainting or dizziness? Yes No
2. Ever had surgery? Yes No 13. Passed out/had chest pain during exercise? Yes No
3. Have recurrent/chronic illnesses? Yes No 14. Had mononucleosis (mono) during the past 12 months? Yes No
4. Had a recent infectious disease? Yes No 15. If female, have problems with periods/menstruation? Yes No
5. Had a recent injury? Yes No 16. Have problems with falling asleep/sleepwalking? Yes No
6. Had asthma/wheezing/shortness of breath? Yes No 17. Ever had back/joint problems? Yes No
7. Have diabetes? Yes No 18. Have a history of bedwetting? Yes No
8. Had seizures? Yes No 19. Have problems with diarrhea/constipation? Yes No
9. Had headaches/migraines? Yes No 20. Have any skin problems? Yes No
10. Wear glasses, contacts or protective eyewear? Yes No 21. Traveled outside the country in the past 9 months? Yes No
11. Have a communicable disease? Yes No (list countries visited and dates below)
Please explain “yes” answers in the space below, noting the number of the questions.
Mental, Emotional and Social Health: Has the camper:
Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD)? Yes No
Ever been treated for emotional or behavioral difficulties and/or eating disorder? Yes No
During the past 12 months, seen a professional to address mental/emotional health concerns? Yes No
Had a significant life event that continues to affect the camper’s life?
(History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, etc.)
Yes No
Please explain “yes” answers in the space below, noting the number of the questions.
Is the camper undergoing treatment at this time, to be continued at camp? Yes, as described below No
Restrictions: I have reviewed the program and activities of the camp and feel that the camper can participate without
restrictions. Yes No (please describe or list specific activities and any recommendations below)
Health-Care Providers:
Name of camper’s primary doctor(s):
Name of dentist(s):
Name of orthodontist(s):
Phone:
Phone:
Phone:
Immunization History:
Camper is up to date on all immunizations:
Yes Required – Date of last tetnus shot: ____/____ (month/year)
No, camper has not been fully immunized and I understand and accept the risks to my child from not being fully immunized.
Signature of Custodial
Parent/Guardian or camper
if over the age of 18
Date
Relationship
to Camper
Girl Scouts of Greater Iowa
Resident Camp Form – Health History Form