Rochester Young Scholars Academy at Geneseo

                 HEALTH EVALUATION FORM

Form Due at Camp Pre-registration, June 14, 2008, Saturday, 10-2pm, Rundell room, Central Library, on 115 South Ave.  First come first serve for Nurse’s Review.

Form MUST have both Physician’s and Parent’s Signature.

(Revised 3/08)


Camper’s Name: _______________________________________ Birthday: _____________ Age: __________

Parent/Guardian: _______________________________________ Phone: ______________________________

Address: __________________________________________________________________________________
Street and number, City/Town, State, Zip Code



If not available, in an emergency please notify:

Name: ____________________________________________ Phone: _________________________________

Address: __________________________________________________________________________________

Street and number, City/Town, State, Zip Code


1) HEALTH HISTORY: To be filled out by a parent within 1 month prior to arrival at camp. Please state allergies, health problems, and recent injuries.
    ____________________________________________________________________________________________________________________

    ____________________________________________________________________________________________________________________

    ____________________________________________________________________________________________________________________


2) PARENT AUTHORIZATION: This statement MUST be signed in order for camper to attend camp.

The health history is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities, except as noted by the examining physician and myself. In the event that I cannot be reached in an EMERGENCY, I hereby give permission to the Camp Health Director to hospitalize and secure proper treatment for my child as named above.

Parent Signature: ___________________________________________________ Date: ________________

Insurance Carrier: _________________________________________________________________________
Plan number/Group number: __­­­­__________________________ ID Number: ________________________



3) IMMUNIZATION RECORDS: attach a copy of physician’s immunization records to this application – a complete immunization record is required by NYS law in order for each camper to attend camp.



4) MEDICAL EXAMINATION: to be completed by a licensed physician

Please give a statement of your evaluation of this camper’s health and fitness to participate in the strenuous activities of camp.

    ____________________________________________________________________________________________________________________

    ____________________________________________________________________________________________________________________

    ____________________________________________________________________________________________________________________


This examination should be performed within 1 year of arrival at camp. If the health history indicates any problems, include any recommendations and restrictions.



Signature of Physician: ___________________________________________ Date: ____________________

Address: _______________________________________________________ Phone: ­­___________________


5) MEDICATION INFORMATION: Any and all medications must be included on this side of the health form. RYSAG has a zero tolerance policy regarding medications - - all medications including prescriptions, over the counter meds, herbal remedies, and dietary supplements must be stored at the health center (not in the cabin with the camper!) and administered by the camp nurse. If a camper is found to be self-administering ANY medication, it will be considered grounds for dismissal from camp!



The following over the counter medications or generic equivalent is available from the camp nurse. Parent and Doctor must indicate which medications may be administered while the child is at camp. Only medications marked “YES” and determined to be necessary will be administered at the discretion of a registered nurse. The nurse will give the child medication “per label directions” unless otherwise specified.


Medication Name (or store brand/generic)

YES

NO
Comments (specific instructions for dosage)

Tylenol (for fever or pain)




Advil (for fever or pain)




Throat Lozenges (for throat irritation)




Benedryl (for allergic reactions)




Sudafed (for stuffy nose)




Calamine Lotion (for insect bites)




Cortizone Cream (for skin irritation)




Immodium AD (for diarrhea)




Pepto Bismol (for upset stomach)




First Aid Cream (for minor cuts/scratches)






Below you must list all medications that will be brought to camp with this camper. This list MUST include all prescriptions, over the counter medications, herbal remedies, and dietary supplements!

Name of Medication/Dosage Reason for Taking

    ____________________________________________________________________________________________________________________

    ____________________________________________________________________________________________________________________

    ____________________________________________________________________________________________________________________

    ____________________________________________________________________________________________________________________

    ____________________________________________________________________________________________________________________

    ____________________________________________________________________________________________________________________