PARENT’S DECLARATION CONCERNING HEALTH OF PARTICIPANT: SRMC 2017
Event Timing: Sept 1-4, 2017
Event Address: Camp Suwanee,
Contact us at (904) 635 5964; (904) 646 7740; or (904) 728-1616
Name of Participant
Your answer
Name and Phone of Emergency Contact
Your answer
Height
Your answer
Weight
Your answer
General Questions
Yes
No
Is the general emotional / mental condition normal?
Is the general physical condition normal?
Is the vision and hearing normal?
Is the nutritional condition normal?
Is there evidence of alcohol or drug dependence?
Is there evidence of infectious disorders?
Is there evidence of sexually transmitted disease?
If answered No, please provide details:
Your answer
Medication:
Prescription or over the counter/self medication). Please ensure sufficient supply for camp’s duration.
Is participant taking medication?
If yes, state condition being treated
Your answer
State Name of Medications, Dosage, Dosage Timing (morning, noon, evening, night) and other medication Instructions (with/ before /after meals, at bedtime, etc., and contraindications, not with food/drink, etc):
Your answer
Restrictions or Recommendations - This Participant may take part in all activities with the following Restrictions or Recommendations:
Provide details of any limitations on participant's activities during the program
Your answer
In case of hospitalization by camp staff, participant’s medical records are available from this Physician or Hospital:
Your answer
Telephone of Physician or Hospital (include area code):
Your answer
Medical History: Apart from minor childhood illnesses, is the participant’s health generally good?
If your child attends a public school or accredited private school, you may list the school and ignore the Immunization History. Name of School
Your answer
Immunization History
Yes
No
DPT (Diphtheria, Pertussis, Tetanus)
Polio
Measles
Chickenpox
Meningoccal
Tetanus
MMR (Measles, Mumps, Rubella)
Hepatitis A
Hepatitis B
Influenza
Pneumococcal
Other:
Has the participant ever had any infectious diseases? Please tick any that apply:
Please provide a brief history/explanation regarding any infectious diseases above and whether they have left any lasting complications:
Your answer
Other issues
Yes
No
Drug reactions
Other allergic reactions (food, animal, plant, give details)
Asthma or other lung / respiratory disorder (give details)
Enuresis (bed wetting)
Endocrinal disorder: Diabetes o Thyroid o (give details):
Epilepsy
Ear / nose / throat disorder (give details):
Frequent Diarrhea or Vomiting
Sleep disorder
Emotional / behavioural counselling (give details
Other disorders (give details):
Wears braces or has “caps” / artificial teeth :
Heart/Blood Pressure Problem:
Stomach Problem:
Heart / Lung Problems
Menstrual Disorder:
Hernia:
Glasses / contact lenses
Physical limitations (give details):
Special diet (give details):
If yes, please give details
Your answer
Please specify if there is anything that the Program staff should be aware of relating to any of the above:
Your answer
Part 9: Parent/Guardian Signature
By typing your name below, the parent agree that the health information is true and correct.
Signature of Parent
Your answer
Date
MM
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DD
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