Camper Health Information Form - Camp Wenonah

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WE WELCOME YOUR COMMENTS: 1. What can the Camp Wenonah staff do to provide the best experience for your child 2. What do you do when your child is upset How do you calm them down 3. Help us understand the social preferences of your child. Does your child most easily make friends with other children who are (please check): My child’s own age Younger Older Adult All ages 4. Are there any recent significant changes in family relationships that may affect your child while he/she is at Camp (please check) Birth Death Illness Separation Divorce Move Other Please explain the nature of the change: 5. What are the eating habits of your child (please check) Fussy Average Hearty 6. Is your child on a special diet (please check) No special diet Vegetarian Does not eat red meat Other (please specify): NOTES ABOUT FOOD SERVICE: Special diet alternatives are available, and MUST be pre-selected. Once selected, that is the menu choice for EACH meal at Camp. No substitutes or switching will be allowed during the Camp Period(s) attending. SLEEP HABITS: 7. a) Please help us understand your child’s sleep patterns. Check all of the following that apply: Frequently wets bed Occasionally wets bed Walks in sleep Nightmares/terrors b) Please explain the nature of your child’s sleep pattern: c) Does your child have any particular fears If yes, please explain. 2 Please see next page….
2013 CAMPER HEALTH FORM: PARENT / GUARDIAN INFORMATION: Main Contact: Alternate Emergency Contact: Family Physician: Name: __________________________ Name: _________________________ Name: ______________________ Relationship: ____________________ Relationship: ____________________ Phone: ______________________ Home Phone: ____________________ Home Phone: ____________________ **If there is on-going medical supervision or care needed, a Work Phone: _____________________ Work Phone: _____________________ referral letter from your doctor will help the Camp Wenonah Cell Phone: ______________________ Cell Phone: ______________________ staff facilitate that care during your child’s stay with us** CAMPER HEALTH INFORMATION: 1. When did your child last have a tetanus booster shot ___________________________ 2. Child’s height: ___________________________ Child’s weight: ___________________________ ALLERGY INFORMATION: 3. What food allergies (if any) does your child have _______________________________________________ Please describe the allergic reaction: __________________________________________________________ Is this food allergy life-threatening Yes No If yes, will your child bring an EPI-PEN to Camp for this food allergy Yes No 4. My child is allergic to the following: Insects Spiders Bees Wasps Drugs: _____________ Environmental: _____________ Please describe the allergic reaction: _____________________________________________________________ Is this allergy life-threatening Yes No If yes, will your child bring an EPI-PEN to Camp for this allergy Yes No Please describe the treatment for this allergy: ______________________________________________________ **If your child is attending a two week or one month period an extra Epi-Pen must be brought to Camp for the outtrips.** **Please send a fanny pack to Camp with your child to carry his/her EPI-PEN** 5. If your child is bringing asthma inhalers to Camp, where should the inhalers be kept With my child at all times (please send a fanny pack to Camp for this purpose) In the Health Centre (inhalers will be sent with your child on all overnight out trips) What triggers an asthma attack How frequently do asthma attacks occur Please see next page…. 3
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Page 5 and 6: MEDICATION: Notes: - All medication

Camper Health Information Form - Camp Wenonah

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