Caribou Creek Corral Health History

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Caribou Creek Corral
Health History
Camper's Name__________________ Date of Birth____________ M__ F__

HT___. WT___.

Physicians name _______________. Physicians phone number___________________.

Health insurance_____________________.

Emergency Contact 1. ____________________. 2.____________________.
Please indicate any active medical diagnosis_____________________. Date of onset_________________.

List any medications camper is currently taking________________________.

Please list any environmental allergies including bee stings______________________.

Please list any food allergies or restrictions_____________________.

Please list any medication allergies_______________________.

*Please fill out attached immunization form.
Consent for Prescription Medications

Prescription medications have been brought to camp. Yes___. No___. If yes, licensed practical nurse will store and administer the medication.

Name of medication____________________. Prescribing MD.___________________.

Dosage___________. How it is taken, i.e. oral, inhalation_________________. Time(s) of day medication is taken___________.

Day(s)/number of days medication is taken. ____________.

Special instructions_______________________________________________.

Consent for Non-prescription Medications

This consent allows Licensed Practical Nurse to give over the counter medications as needed during the camp session without contacting you. Please check yes for any medication camper is allowed to take.

Tylenol-for headache or minor pain. Yes___. No___.

Tums- for upset stomach. Yes___. No___.

Halls or Vicks cough drop for minor cough. Yes___. No___.

Triple Antibiotic Ointment-for minor cuts or abrasions. Yes___. No___.

Caladryl-for skin irritations with itching. Yes___. No___.

Aloe-for sunburn. Yes___. No___.

Benadryl-for allergy symptoms or bee sting. Yes___. No___.

First Aid burn cream-for minor burns. Yes___. No___.

Hydrocortisone 1%- for relief of minor skin irritation with itching. Yes___. No___.
Statement of Release and Authorization:

1. I hereby agree to release and hold Caribou Creek Corral staff free and harmless for any claims, demand, or suits for damages from any injury or complication that may result from the proper administration of the Non-Prescription Medications, which I have voluntarily marked "yes," and the Prescription Medications the camper brings to camp with them.

2. In case of emergency, where the camper needs to be seen by a physician, I hereby give my permission for my child to be transported to a medical facility or hospital for the purpose of conducting examinations, ordering x-rays, administering tests and or receiving emergency treatment.
Signature of parent or guardian_____________________________. Date___________.

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