Camp Good News - Health Form (rev. in 2008)
Camper’s Name: ____________________________________ Camp Date: __________________
Male _________ Female _________ Age ________ Date of Birth ______/______/______
EMERGENCY CONTACTS
NAME:___________________________________________________RELATION:________________________________________________
HM PHONE:____________________________CELL:_______________________________ WK:____________________________________
Please give all dates of Immunization for (or include a copy of ) shot records:
Which of the following has the participant had? IF A CAMPER IN previous year, records are here,
BUT please update any new vaccines, allergies, etc. Also give permission for routine meds like Tylenol.
Vaccine Dates: (M/Yr )
DPT ____ ____/ ____ ____ ____ ____
Vavivax (Chicken Pox) ____ ____/ ____ ____ ____ ____
Measles, Mumps, Rubella ____ ____/ ____ ____ ____ ____
Hepatitis C ____ ____/ ____ ____ ____ ____
Tetanus ____ ____ / ____ ____ ____ ____
Hepatitis A,B,C ____ ____/ ____ ____ ____ ____
Polio ____ ____ / ____ ____ ____ ____
Haemophilus Influenza B ____ ____/ ____ ____ ____ ____
TB Mantous Test ____ ____ / ____ ____ ____ ____
Date of last test ____ ____/ ____ ____ ____ ____
Result: Positive Negative ____ ____/ ____ ____ ____ ____
Allergies: medications______________________type of reaction ___________________________
food/other__________________________ type of reaction ________________________________
Emotional or Behavior Problems: ____________________________________________________
Medication Requirements: All medicine must be in original container labeled with camper’s name.
Enclose medications in a ZIP-LOC bag with camper’sname and give to nurse at registration.
Medication:_______________________________________________________________________
Dosage:___________________________________________________________________________ Reason:___________________________________________________________________________
Permission to Treat Camper:
Below are the medications that are kept in stock at the nurse’s station.
Please check the types your child may receive.
_____Tylenol _____Antacid Medicine_____Antihistamine (allergy)______Ibuprofen _____Robitussin DM (Cough) _____Decongestion
Special Health Considerations: ___________________________________________________
Disabilities: ___________________________________________________________________
Camp Good News Clarification: Our camper’s insurance begins where yours terminates.
It is only valid when your policy has been extended to its limit. In the event you have no personal
organizational insurance, Camp Good News can arrange adequate emergency medical coverage
(with $5,000 maximum coverage).The Health History is correct as far as I know, and the person herein has my permission to engage in all camp activities, except as noted by me and/or attending physician.
I give my permission to the physician selected by the Director of Camp Good News to hospitalize,
secure proper treatment for, and to order injections, anesthesia, or surgery for the child named above. I also give permission to the Camp Good News Health Officer to give routine, non-surgical treatment.
Signature of Parent or Guardian __________________________ Date:___________
Camp Good News
Picture Release Form
I hereby consent to the use (full or in part) of all videotapes and/or
pictures taken of my child/children by Camp Good News staff for advertisment purposes.
Camper’s Name _____________________________________Address____________________________________
City _________________State _________ Zip Code ___________ Date ______/_______/_______
Legal guardian ___________________________________
(signature)
Legal guardian ___________________________________
(print name)
Address ______________________________________________
City _________________________________________________
State ____________ Zip Code _________ Date ______/______/_____
Please fax or mail to:
2009 Orientation Form
Please read the following information carefully.
DROP OFF NEW
Beginning this year the Sunday evening drop off time is 6:00-7:00PM. We find this to be a necessary change for both staff and many parents. Gates will not be opened and NO CHILD will be received before 6:00 PM. Dinner will not be served on Sunday but for your convenience the Snack Shack will be opened and kids will be allowed to purchase snacks.
CAMPER VISITATION
For the safety of ALL campers there is a designated time for family visitation, which is on Tuesday from
6:00 - 7:30 PM. ONLY those on the approved pick up list can visit the campers and they must check in at the camp office and show proper ID such as a state drivers license.
CELL PHONES
Campers are NOT ALLOWED TO POSESS CELL PHONE WHILE ATTENDING CAMP GOOD NEWS. If a camper is caught with a cell phone parents will be called and campers will be required to leave Camp Good News. If your child becomes ill or there is an emergency you will be called immediately by a camp leader.
MEDICATIONS
State laws require and regulate that medications be handled a specific way. ALL medications, both prescription and nonprescription, will be handled by the camp nurse. ALL medications must be checked in with clear written detailed instructions. The camp nurse will be on site Sunday evening and Monday mornings to receive all medications.
CLOSING CEREMONIES
Friday closing ceremonies will begin at 5:00 PM and the gates will be opened at 4:30 PM. Please join us for this exciting time when the kids get to “show off” some of their newly learned songs and skits. Immediately following the closing ceremony there will be FREE hot dogs & drinks for families and campers. We hope you will join us for this time of fellowship.
PLEASE SIGN THEREBY ACKNOWLEDGING YOUR UNDERSTANDING AND
COMPLIANCE TO THE ORIENTATION GUIDELINES.
THANK YOU,
Camp Good News Staff
Parent/Guardian Signature
_________________________________________________Date___________________
Printed Name
_________________________________________________Date___________________
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