Medical Application - June 11th - 17th, 2017
For Child's Doctor to Complete.

Questions can be directed to apply@clarksvillecamprainbow.org or Jereme Miner, Camp Director: 931-320-3473.

Child's Last Name:
Your answer
Child's First Name:
Your answer
Child's Date of Birth:
MM
/
DD
/
YYYY
Weight:
Your answer
Height:
Your answer
Physician's Information:
Physician's Name:
Your answer
Practice Name:
Your answer
Street:
Your answer
City:
Your answer
State:
Your answer
Zip Code:
Your answer
Office Phone:
Your answer
Office fax:
Your answer
After Hours Contact Numbers:
Your answer
Date of child's last exam or office visit:
Your answer
Child's diagnosis and original date of diagnosis (please indicate if in remission):
Your answer
** With this application, children with Cystic Fibrosis must provide sputum culture proof of no multiple drug resistant pseudomonas**
Culture Done:
Your answer
N/A:
Your answer
Other diagnosis, not related to primary diagnosis:
Your answer
Other helpful information:
Your answer
What other medical treatments or procedures will the Camp Rainbow Nursing Staff need to provide the week of camp besides medications?
(Examples; urinary cauterization, breathing treatments, Chest percussion, G Tube feedings, wound dressing changes)
Your answer
Medications given to the child at home:
Medication Name, Amount Give, and How Often
Your answer
Medications the child should take while at Camp during the week of June 11th - 17th, 2017
Your answer
Allergies
Any known allergies to medications (Please List):
Your answer
Is the child allergic to any medications? If Yes, please list:
Your answer
Any Latex allergies?
Your answer
Has the child had Chicken Pox?
Your answer
Any treatments or surgeries prior to Camp?
Your answer
Any diet restrictions while at Camp?
Your answer
Any lab work required while the child is at Camp?
Your answer
Immunization Record
Please complete this section below.
DTaP/Hep B/IPV (# and Date:)
Your answer
Hepatitis B (# and Date:)
Your answer
DtaP/DT/Td (# and Date:)
Your answer
DtaP/Hib (# and Date:)
Your answer
Td Booster (# and Date:)
Your answer
Hib (# and Date:)
Your answer
Hib/Hep B Tdap (# and Date:)
Your answer
Polio (# and Date:)
Your answer
Pneum Conj (PCV) (# and Date:)
Your answer
MMR (# and Date:)
Your answer
Varicella (# and Date:)
Your answer
Hepatitis A (# and Date:)
Your answer
Meningococcal (# and Date:)
Your answer
The information status on the above named child is accurate according to the best available information on file.
By agreeing to the terms and conditions you are confirming the above information is accurate and current to the best of your knowledge.
Do you agree to these terms and conditions?
Physician's Signature:
Please type your name:
Your answer
Date:
Your answer
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