Medical Consent – Health Form

Camper Information
Program Attending*
- Camp
- LYTE
Dates Attending*
From
MM slash DD slash YYYY
Thru*
Thru
MM slash DD slash YYYY
Child's Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Age*
Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female
Parent/Guardian Name*
First Last
Day Time Phone*
Cell Phone
Parent/Guardian Name
First Last
Day Time Phone
Cell Phone
Emergency Contact*
First Last
Day Time Phone*
Cell Phone
Required Medical Information
We REQUIRE this information to provide appropriate medical care in event of injury and/or illness while at camp. We are committed to protecting the confidentiality of this information.
Do you carry medical/hospital insurance?
- Yes
- No
Insurance Carrier
Policy #
Insurance Phone
Name of Responsible Party
Family Physician
Name
Physician Phone
Health History
General Questions: Check "Yes" or "No" for each statement. Has the camper:
1. Ever been hopitalized or had surgery?*
- Yes
- No
2. Have recurrent / chronic illness?*
- Yes
- No
3. Had a recent illness or infectious disease?*
- Yes
- No
4. Wear glasses, contacts or protective wear?*
- Yes
- No
5. Have a history of bed wetting?*
- Yes
- No
6. Have any skin problems (rash, itching, etc)?*
- Yes
- No
7. Have diabetes?*
- Yes
- No
8. Have asthma/wheezing/shortness of breath?*
- Yes
- No
9. Have frequent headaches?*
- Yes
- No
10. Had a head injury/been knocked unconcious?*
- Yes
- No
11. Ever had seizures?*
- Yes
- No
12. Ever been diagnosed with migranes?*
- Yes
- No
13. Have allergies (seasonal, food, mediation, etc)?*
- Yes
- No
14. Ever had an eating disorder?*
- Yes
- No
15. Ever been dizzy/passed out during or after exercise?*
- Yes
- No
16. Ever had chest pain during or after exercise?*
- Yes
- No
17. Ever been diagnosed with heart murmur?*
- Yes
- No
18. Ever had high blood pressure?*
- Yes
- No
19. Ever had back problems?*
- Yes
- No
20. Ever had problems with joints (knee, ankles, etc)?*
- Yes
- No
21. Have an orthopedic appliance being brought to camp?*
- Yes
- No
22. Had fainting or dizziness?*
- Yes
- No
23. Had mononucleosis(mono) in past 12 months?*
- Yes
- No
24. Have problems with diarrhea/constipation?*
- Yes
- No
25. Have a history of sleepwalking?*
- Yes
- No
26. If female, any problems with menstrual history?
- Yes
- No
27. Ever had any emotional problems for which professional help was sought?*
- Yes
- No
Please explain “Yes” answers in the space below, noting the number of the questions.
IMMUNIZATIONS: Please fill in the information below or attach a recent copy of your child’s immunization record.
1. All immunizations up to date*
- Yes
- No
2. Polio (OPV or IPV)
- Yes
- No
Polio Date*
MM slash DD slash YYYY
3. Varicella (Chicken Pox)
- Yes
- No
4. DTP/DTap/DT/TD (Diphtheria, Tetanus, Acellular Pertussis or Tetanus and Diptheria only)
- Yes
- No
Varicella Date*
MM slash DD slash YYYY
DTP/DTap/DT/TD Date*
MM slash DD slash YYYY
5. MMR (Measles, Mumps, Rubella)
- Yes
- No
6. Hepatitis B
- Yes
- No
MMR Date*
MM slash DD slash YYYY
Hepatitis Date*
MM slash DD slash YYYY
Please List ALL Allergies:
Drug
Insect/Plant
Food
Diet Restrictions
List ANY Medications Camper will require at camp and reason. (Prescriptions medications MUST have completed medical form)
PARENT/GUARDIAN PLEASE READ AND SIGN BELOW:
ALL prescription medications, over-the-counter medications, vitamins, and herbal products that are provided for staff to administer to your child MUST be in ORIGINAL containers with labels and dispensing instructions in English and COMPLETED medical form signed by doctor for all prescription medication.

PERMISSION TO ADMINISTER OVER THE COUNTER MEDICATIONS: In event of minor illness at camp, I give my informed consent to the First Aid personnel to provide basic First Aid and comfort measures which include the use of common over-the-counter remedies in appropriate age/weight dosages. I authorize the use of /but not limited to the following over-the-counter medications as directed by the labels provided by the manufacturer for my child: analgesics, decongestants, antihistamines, cough suppressant, throat lozenges or spray, anti-nausea/diarrhea, epi-pen, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin/wound cleansers, ipecac, glucose, laxatives, electrolyte replacement fluids, analgesic balms/gels. I understand that these are stocked and dispensed by personnel free of charge as needed for the comfort of my child.

PERMISSION TO TREAT: I, the undersigned parent or legal guardian of the child named above, do hereby authorize and consent Youth Helpers, Inc., to provide to the above name child routine health care and to administer medications as detailed above. It is understood that in the case of an emergency every effort will be made to contact the undersigned prior to rendering treatment to the patient, but treatment will not be withheld if the undersigned cannot be reached. In case of emergency I authorize Youth Helpers, Inc. to order any x-ray examination, anesthetic, medical or surgical treatment rendered by medical or emergency professionals licensed under the provisions of the Medicine Practice Act, or dentist licensed under the provisions of the Dental Practice Act and on the staff of any general hospital in the state of CA, Department of Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care deemed advisable by aforementioned physician in the exercise of the doctor’s best judgement. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of CA. I authorize Youth Helpers to arrange for or provide any necessary related transportation to the nearest medical facility for urgent or emergency medical treatment if indicated, and I do assume all responsibility for payment for such treatment. This completed form may be photocopied for trips away from camp.

I acknowledge that I have read completely and fully understand all aspects of this form and I agree to the terms contained within them in their entirety.
Signature*
Date
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

Medical Consent – Health Form

Camper Information

Required Medical Information

Health History

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