Personal Health and Parental Consent and shirt size

Personal health and medical history

SHIRT SIZE_____

 

To be filled out by parent, guardian, or adult participant.  Please print in ink.

 

Identification          - Grade in School 2012-13 yr- 5TH   6th   7th   8th   9th   10^th11th 12^th,  Adult (circle one)

Young Women

Name ____________________________________________________             Date of Birth _______________________   Age ___________

Address __________________________________________________             e-mail address ______________________________________

Home Phone ______________________________________________             Cell Phone _________________________________________

Parents/Guardians

Father ___________________________________________________              Work Phone ________________________________________

                                                                                                                Cell Phone _________________________________________

Mother ___________________________________________________             Work Phone ________________________________________

                                                                                                                Cell Phone _________________________________________

If the persons named above cannot be reached in case of an emergency, please notify

Name __________________________________________  Relationship ________________  Telephone ________________________

Name __________________________________________  Relationship ________________  Telephone ________________________

Medical/Health History

Name of Physician _________________________________________              Telephone _________________________________________

Check all items that apply, past or present, to your health history.  Explain any “Yes” answers.

Allergies:  Food, medicines, insects, plants    Yes G       No G       Explain: ___________________________________________

_______________________________________________________________________________________________________________

General Information              Yes          No                                                 Yes         No                                        Yes          No

ADHD (Attention-Deficit                

   Hyperactivity Disorder        G              G              Convulsions/seizures     G       G          Hemophilia            G             G

Asthma                                   G              G              Diabetes                       G            G          High blood pressure G          G

Cancer/leukemia                  G              G              Heart trouble               G            G          Kidney Disease      G             G

Epilepsy                                  G              G              Fainting spells             G            G          Mental condition   G             G

Recent surgery                      G              G              Recent injury               G            G          Recent illness        G             G

 

Explain any “yes” answer: ________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

List any medications to be taken while participating in camp. _________________________________________________________

_______________________________________________________________________________________________________________

List any physical conditions that may affect or limit full participation in any of the activities.  (hiking, biking, canoeing, zip line, rappelling, archery, riffle shooting) ________________________________________________________________________________

_______________________________________________________________________________________________________________

List any equipment needed at camp: (wheelchair, crutches, braces, glasses, contact lenses, breathing treatments etc.) _______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

All prescribed medications must be sent to camp in their original containers with the label intact.  Over-the-counter medication must be labeled with the girl’s name, date and dispensing instructions (amount to administer and frequency).           

           

Immunizations: (Give date of last inoculation.)

Tetanus toxoid __________________________ Measles _________________________               Polio ____________________________

Diphtheria       __________________________   Mumps __________________________               _________________________________

Pertussis          __________________________   Rubella _________________________                _________________________________

 

 

 

 

 

Insurance Information (You can attach a copy of your insurance card or fill out the section below)

 

Primary Insurance Coverage

Name of policy holder ____________________________________ Social Security Number  _____________________________

Address  ________________________________________________                Date of birth _______________________________________

Employer ______________________________________________________________________________________________________

Personal health/accident insurance carrier _________________________________________________________________________

Address _________________________________________________________________ Telephone ____________________________

Policy Number ___________________________________________ Group Number _____________________________________

Effective date ___________________________________________

 

Secondary  Insurance Coverage

Name of policy holder ____________________________________ Social Security Number  _____________________________

Address  ________________________________________________                Date of birth _______________________________________

Employer ______________________________________________________________________________________________________

Personal health/accident insurance carrier _________________________________________________________________________

Address _________________________________________________________________ Telephone ____________________________

Policy Number ___________________________________________ Group Number _____________________________________

Effective date _______________________________________

 

Parental Consent

I give permission for full participation in the Lake Mead Stake Girl’s Camp, subject to limitation noted herein.

 

In case of emergency, I understand that every effort will be made to contact me (if participant is an adult, my spouse or next of kin).  In the event I cannot be reached, I hereby give permission to the licensed health-care practitioner selected by the adult leader in charge to secure proper medical treatment, including transportation to medical facility, anesthesia, surgery, or injections of medication for my child (or for me, if participant is an adult).  I guarantee payment of all expenses incurred for such transportation and treatment.

 

This child (or adult) has no health, emotional, or injury related conditions (recent or chronic) will be aggravated by or which will exclude her active participation in camp.  This child (or adult) has seen a physician in the last year.

 

This authorization shall cover all camp activities and travel to and from camp.

 

 

 

 

Parent/Guardian Signature: ___________________________________________    Date: _____________