Microsoft word - camper application_2012.doc

FOR OFFICE USE ONLY
3=Moderate Persistent 4=Severe Persistent CAMPER HEALTH FORM
GENERAL INFORMATION (to be completed by parent/guardian)
Please provide name and address of the school your child will be entering in the fall? ___________________________________________________________________________________ EMERGENCY CONTACT INFORMATION
Father: Check if Primary Residence
Mother: Check if Primary Residence
Guardian(s): Check if Primary Residence
________________________________________ _______________________________________ _______________________________________ E-mail
What county does your camper live in? ______________________ What T-shirt size for camper? (Adult sizes only) XS S M L XL XXL
Who will be the primary contact while your child is at camp?
Who is (are) the legal guardian(s) for this child? Are there any custody or visitation restrictions? Yes No If yes, please describe
CONFIDENTIAL – ASTHMA CAMP – CAMPER HEALTH FORM – PAGE 1 If not available in an emergency, please notify (this must be filled out) CAMPER INFORMATION
Has your child:
Yes No If so, what year? _________
Yes No Name and location
Attended other residential non-asthma camps? Yes No Name and location
Yes No Explain
Ever been away from home and parents for five days or more? Yes No Explain
Yes No Explain
Been placed on any activity restrictions? HEALTHCARE PROVIDER INFORMATION
Please indicate all healthcare providers your child presently sees:
BEHAVIORAL HISTORY
Our goal is to assist all campers in having a safe and positive camp experience. Personal information is as important as medical information in meeting this goal. All information will be kept confidential with your camper’s healthcare team. Does your child have any behavioral issues at school and/or camp (if applicable) we should be aware of? What methods have worked to positively redirect your child at home or school? Is your child self-conscious about his/her asthma (e.g., using an inhaler in public)? CONFIDENTIAL – ASTHMA CAMP – CAMPER HEALTH FORM – PAGE 2 CAMPER HEALTH HISTORY
(to be completed by camper’s parent/guardian) Most recent
immunization dates: DPT / / MMR / /

Tetanus Booster / / H1N1 / /__ (Note – H1N1 required to attend camp)
Immunization record REQUIRED or child will be denied to attend camp.

Has your child had any of the following illnesses?
Measles Yes No Date: ____/____/_____ Chicken
Yes No Date: ____/____/_____
Yes No Date: ____/____/_____ Mumps
Yes No Date: ____/____/_____
Does your child have any of the following health concerns?
Yes No Fainting
Yes No Discipline
Hyperactivity Yes No
Yes No *Bedwetting
Yes No ADD/OCD
* Please send sheets & blankets instead of sleeping bags. If you answered yes to any of the above, please explain:
Are there any present physical education restrictions at school?
Are there other medical conditions, other than asthma and allergies, for which your child is being treated or
followed by a health care provider?
Who is responsible for giving your child asthma medication at home?
Does your child use a peak flow meter?
If yes, what is your child’s normal reading?
Does your child have a written asthma action plan?
No If yes, please attach.
What brand of peak flow meter?
Do they use it regularly?
Does your child use a spacer or holding chamber with his/her inhaler?
No If yes, which one? ______
Is there any medication treatment you prefer not be used at camp for your child? ____________________________
On a scale of 0 to 10, how would your rank your child’s asthma? (Circle only one number)
CONFIDENTIAL – ASTHMA CAMP – CAMPER HEALTH FORM – PAGE 3 ALL MEDICATIONS
Please include asthma and non-asthma medications
DRUG NAME (indicate if it is an inhaler, nebulizer, liquid or pill)
STRENGTH DOSAGE FREQUENCY
What would you give your child for a headache? _____________________________________________________
What would you give your child for an upset stomach? ________________________________________________
Does your child prefer liquid, tablet, capsule or chewable form? ________________________________________
* Please initial if it is ok to give your child these medications if needed. ______ We will call you if the symptoms persist.
HISTORY OF ASTHMA
WITHIN THE PAST 3 MONTHS, (on the average): How many nights per week does your child wake up because of asthma or coughing? How much does your child’s asthma interfere with exercise? How many days per week does your child need to use their reliever (rescue inhaler)? Days per week WITHIN THE PAST YEAR ONLY, how many times has your child: Been home from school because of asthma? How often would a parent or guardian have missed work to monitor your child’s asthma? Number of days _____________ Went to the doctor’s office because of difficulty with his/her asthma? Been to the emergency room or urgent care clinic because of asthma? Been on oral corticosteroids. How many courses have been taken? (NOTE: Oral corticosteroids are medications taken by mouth in either pill or liquid form, and are usually used when other medications
cannot adequately control asthma symptoms. Names of oral corticosteroids include: PILLS: Prednisone, Medrol, Deltasone, Decadron and
others LIQUIDS: Pediapred, Prelone, Liquidpred and others.)
CONFIDENTIAL – ASTHMA CAMP – CAMPER HEALTH FORM – PAGE 4 WITHIN THE PAST 5 YEARS, has your child been: No How many times?
No How many times?
No How many times?
ALLERGY INFORMATION
Is your child allergic to any:

MEDICATION (penicillin, sulfa, etc.)?
Date of Last
Medication Name
Reaction (be specific)
Reaction
Age of Last
Reaction (be specific)
Reaction

Does your child need to have special food preparation? Or can they just avoid food allergens? Please explain.
_________________________________________________________________________________________________
_________________________________________________________________________________________________ What has your physician advised you to do if an allergic reaction has occurred? _____________________________
_________________________________________________________________________________________________ ANIMALS or INSECTS?
Age of Last
Animal or Insect
Reaction (be specific)
Reaction

What has your physician advised you to do if an allergic reaction has occurred? _____________________________
__________________________________________________________________________________________________ CONFIDENTIAL – ASTHMA CAMP – CAMPER HEALTH FORM – PAGE 5 PARENT/GUARDIAN AUTHORIZATION
PARTICIPATION AND EMERGENCY TREATMENT WAIVER
In consideration for being allowed to register and participate in Camp Catch-Ya-Breath, as
parent/guardian I hereby release the camp, its Incorporators, Physicians, Board Members, Officers,
Employees, Agents, Independent Contractors and Volunteer Workers from any liability for injuries which
are sustained during the camp, including any necessary transportation. The child herein described
has permission to engage in all scheduled activities except as noted by the physician or
parent/guardian. I hereby give permission to the camp physician to initiate and provide any necessary
treatments, including transporting to the nearest certified emergency facility. If hospitalization is
required, the child is to be referred to an appropriate physician and all treatments will be at my expense.
PHOTOGRAPHY, VIDEO AND PROMOTIONAL RELEASE
I do hereby acknowledge and authorize Camp Catch-Ya-Breath in Potosi, Missouri to take and use
photographs, video and written comments of or by my child for promotional and informational materials.
Further, I agree to release and discharge Camp Catch-Ya-Breath in Potosi, Missouri and its sponsors
from any and all liability in connection with the use of such photographs, videos and written comments of
or by my child.
RELEASE OF TRANSPORT HOME
At the conclusion of camp, the Camp Staff may release my child to me, or to the individual(s) designated below. Under no
circumstances will your child be released to anyone not specified by you. Picture ID may be required.
… I will be picking up my own child. Alternate adult designated to pick up my child for me. Name ***We need your signature below even if YOU are planning on picking up your child. ***


AUTHORIZATION TO RELEASE MEDICAL DATA
I do hereby authorize Camp Catch-Ya-Breath in Potosi, Missouri to release medical data for the purpose
of compiling and assessing national asthma medical information. I understand that all data will be
analyzed in aggregate form protecting the confidentiality of my child.
CONFIDENTIAL – ASTHMA CAMP – CAMPER HEALTH FORM – PAGE 6 CAMPER CODE OF CONDUCT
(Please review with your child)
It is our hope that everyone that participates in our program will have a positive experience that will last a lifetime.
To help everyone get the most out of their camp experience, we have set up a list of ground rules to help parents
and children understand what we expect at camp. We recognize the special needs of our campers and will as
much as possible; individualize the rules according to the needs and abilities of each camper.
Camp has four basic rules that we explain to the children and also post in the cabins. We have these rules so
that everyone can be assured of a positive experience.
• Respect yourself, others and property. This means abusiveness toward others or using inappropriate
language, fighting, stealing, etc. It also covers property damage, graffiti or vandalism. Respect yourself, refers to keeping your things picked up, personal hygiene and taking your medication on time.
• Participate in camp activities. It is camp’s responsibility to know where all the campers are at all times. We
ask campers to be at all activities unless excused by staff. Campers cannot be left alone in their cabin.
• Follow directions. There are a lot of fun things to do at camp but every activity has rules so we can operate
the activity safely and appropriately. We ask the campers to follow staff direction during these activities.
• No put-downs. Examples of this would include teasing, name-calling, racial slurs or inappropriate practical

If we do have a problem with inappropriate behavior, we have a camper behavior response policy. The counselor
will start by giving the child a warning, and then a time-out with an explanation and discussion on what is causing
the problem. If the counselor needs help, a behavioral specialist or the designated healthcare team supervisor on
site will work with the child to help avoid further problems. We will also call home to find out if the parents have
any suggestions on ways to deter the inappropriate behavior. As a last resort, we may need to send a child
home. Sometimes in the case of severe homesickness or if misbehavior could cause immediate harm to
themselves or others, we reserve the right to immediately ask that the child be removed from camp.
It is our hope that each child will go home with great memories of camp. These rules are designed to protect the
camper’s experience so that one unruly child won’t ruin the experience for the rest. If you have any questions or
comments, please feel free to call. It is our mission to provide a quality experience for everyone.
***In the event your child needs to be escorted home due to poor behavior, you, as parent/guardian, hereby
release the Association, its Incorporators, Physicians, Board Members, Officers, Employees, Agents, Independent
Contractors and Volunteer Workers from any liability.
I understand and accept that my child must abide by the Camper Code of Conduct


Please have your child sign
I agree to abide by the Camper Code of Conduct
CONFIDENTIAL – ASTHMA CAMP – CAMPER HEALTH FORM – PAGE 7 ASTHMA CAMP MEDICAL HISTORY AND PHYSICAL EXAMINATION
( To be completed & signed by the child’s healthcare provider)
An important note to Healthcare Providers:
This Medical History and Physical Examination form is a mandatory part of your patient’s asthma camp application. If
applicable, please try to simplify the medication regime that the child follows during camp. For example: if a medication can
be given TID, with meals, instead of QID (or BID instead of TID), this would be helpful for the child and the medical
personnel. Furthermore, inhalation therapy with a nebulizer can be time consuming for the child at camp; please carefully
review the child’s need for this form of therapy. Also, allergy shots will not be given at camp.

Child’s name
Date of last physical exam
Immunization Dates (or attach copy of immunization record) Please circle Yes (Y) or No (N)
Y / N Date of last appointment
2. Have there been any hospitalizations for asthma in the PAST 5 YEARS? Y / N How many?
Date of most recent hospitalization (month, year) a. In the ICU or intubated because of asthma in the PAST 5 YEARS? Y / N How many times?
Date of most recent ICU admittance or intubation? / / b. On oral corticosteroids within the PAST YEAR? Y / N How many times?
c. Hospitalized for reasons other than asthma? Y / N How many times?
4. Has this child received the following tests or evaluations in the past year? 5. Does this child have any of the following problems? Y / N Discipline
Y / N Fainting
Y / N Sleepwalking
Y / N Bedwetting
Y / N Constipation
6. Does the Camp Healthcare team need to be aware of any of the following: a. Known medical problems, besides asthma? b. Known behavioral or psychological issues? c. Foods that must be completely eliminated from this patient’s camp diet? d. Other allergy or sensitivity problems? f. Treatments you prefer not be used at camp?
g. Restrictions/limitations on participation in any asthma camp activities? Please explain any “yes” answers (please 7. Based on the NHLBI’s guidelines severity classification, how would you classify this child’s asthma? 8. How would you rate the severity of this child’s asthma on a scale of 0 – 10? (Circle one number only) CONFIDENTIAL – ASTHMA CAMP – CAMPER HEALTH FORM – PAGE 8 MEDICATIONS
Please include asthma and non-asthma medications
DRUG NAME (include if it is an inhaler, nebulizer or pill)
STRENGTH DOSAGE FREQUENCY
ALLERGY INFORMATION
Is this child allergic to any:
MEDICATION?
Medication
Reaction (be specific)
Age of Last Reaction
Reaction (be specific)
Age of Last Reaction
ANIMALS or INSECTS?
Animal or Insect
Reaction (be specific)
Age of Last Reaction
HEALTHCARE PROVDER’S AUTHORIZATION- required
I have examined the above camp applicant. My signature below indicates that I believe this patient is able to participate in an active camp program designed for children with asthma. Healthcare Provider Signature Printed
Would you volunteer at camp?
Please complete and return to the Parent/Guardian.
CONFIDENTIAL – ASTHMA CAMP – CAMPER HEALTH FORM – PAGE 9 We would like to know how you currently feel about your child’s asthma.  Please take a few moments to answer the following questions.  Circle the number that most accurately reflects you or your child’s feelings.    1.  My child’s asthma diagnosis is scary to me.  (1 being not at all, 5 being  2. I feel comfortable caring for my child’s asthma.  (1 being very comfortable,  3.  I am confident I know which medicine to give my child when they are  having sudden symptoms.  (1 being very comfortable, 5 being not at all) 1  4.  I am confident I know which medicine to give my child when they are not  having sudden symptoms.  (1 being very comfortable, 5 being not at all) 1  5.  My child is scared by asthma. (1 being not scared, 5 being terrified.)  6. I am confident my child knows how to care for his/her asthma.  (1 being  very comfortable, 5 being not at all) 1  7. I am confident my child knows which medicine to take when they are  having sudden symptoms.  (1 being very comfortable, 5 being not at all) 1  8. I am confident my child knows which medicine to take when they are not  having sudden symptoms.  (1 being very comfortable, 5 being not at all) 1 

Source: https://wcmhosp.org/files/1332511517_CamperApp.pdf