Camp Morasha Medical Form

Camp Morasha Medical Form

To Be Filled Out By Parent / Doctor / Office

Winter Address: 1118 Ave J Brooklyn, NY 11230 - Tel: 718-252-9696 - Fax: 718-252-7369

Summer Address: 274 High Lake Road Lakewood, PA 18439 - Tel: 570-798-2781 - Fax: 570-798-2966

Camper/Staff Information

Camper Name:

Male Female Camper Staff Kollel

Date of Birth: Age at Camp:

Home Number:

Address:

City: State: Zip:

Cell # (For Staff Only):

Emergency Contacts

Primary parent/guardian to be contacted in case of illness or injury:

MOM Name: E-mail:

Cell # Business #

DAD Name: E-mail:

Cell # Business #

Primary emergency contact, other than parents (REQUIRED!)

Name: Relationship:

Home #: Cell #:

Secondary emergency contact, other than parents (REQUIRED!)

Name: Relationship:

Home #: Cell #:

Health Care Providers

Primary Doctor: Phone:

Dentist: Phone:

Orthodontist: Phone:

Diet / Nutrition

Eats a regular diet Eats a regular vegetarian diet

Has special food needs:

A photocopy of front & back of insurance cards (medical and pharmacy) on the enclosed form must be submitted.

This health history is correct and accurately reflects the status of the camper to whom it pertains. The person described has permission to participate in all activities except as noted by me and/or an examining physician. I give permission for treatment and transportation as needed. If your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being fully immunized.

Does camper use inhaler or epi pen? If yes, what are they allergic to? No Yes,

Does camper take medication on a routine basis? No Yes

Medication Dosage Times Taken Reason

Medication Dosage Times Taken Reason

General, Mental, Emotional, & Social Health

Check “Yes” or “No” for each statement. Explain “Yes” below.

1. Hospitalizations? Yes No

2. Surgery? Yes No

3. Recurrent / chronic illnesses? Yes No

4. Recent infectious disease? Yes No

5. Recent injury? Yes No

6. Seizures? Yes No

7. Fainting or dizziness? Yes No

8. Headaches? Yes No

9. Fainting / chest pain during exercise? Yes No

10. Diarrhea / constipation problems? Yes No

11. Bedwetting? Yes No

12. Falling asleep/sleepwalking? Yes No

13. Back / joint problems? Yes No

14. Skin problems? Yes No

15. Diabetes? Yes No

16. Allergies? Yes No

17. Uses an epi pen? Yes No

If yes, can it be kept in bunk? Yes No

18. Asthma, wheezing, shortness of breath? Yes No

19. Uses an inhaler? Yes No

20. Outside country in the past 9 months? Yes No

21. Wears glasses or contacts? Yes No

22. Had "mono" in the past 12 months? Yes No

23. Problems with periods / menstruation? Yes No

24. Ever been treated for emotional or behavioral difficulties or an eating disorder? Yes No

25. The past 12 months, seen a professional to address mental/emotional health concerns? Yes No

26. Been treated for Attention Deficit Disorder (ADD) or Attention Deficit/Hyperactivity Disorder? Yes No

27. Had a life event that continues to affect the camper’s life? Yes No

Please explain “Yes” answers below:

Camp Morasha Medical Form - To Be Filled Out By Doctor

Full Name: Date of Birth: Camper Staff Member Kollel

Camp Morasha requires a physical exam dated within last 12 months.

Immunization History

Please provide the month and year for each immunization.

Diphtheria, tetanus, pertussis (DTaP or TdaP):

Mumps, measles, rubella (MMR):

Polio (IPV):

Haemophilus influenzae type B (HIB):

Pneumococcal (PCV):

Hepatitis B:

Hepatitis A:

Varicella (Chicken Pox): Had chicken pox? Date:

Meningococcal meningitis (MCV4):

Tetanus Booster (dT or TdaP) Most Recent Dose:

Physical exam done today? Yes No, date of last physical:

Weight: Height: Blood Pressure: Pulse:

Chronic or current illness:

The camper is undergoing treatment at this time for the following conditions:

Diet / Nutrition / Activity

Eats a regular diet Medically prescribed diet or dietary restrictions:

Do you feel that the camper will require limitations or restrictions to activity while at camp? No Yes:

No known allergies List all allergies reactions and treatments:

Medication

No daily medication Yes daily medication (Include name(s), dose(s), frequency and reason for taking):

Other treatments / therapies to be continued at camp:

Epipen Has history of Asthma Inhaler Other:

Physician Authorization:

It is my opinion that the camper is physically and emotionally fit to participate in an active camp program (except as noted above).

Address: City: State: Zip: Phone:

Medical Insurance

We require one copy of this form for every registered camper and staff member. Please make sure copy is legible!

Name (as it appears on the policy): Camper Staff Kollel

Birth Date: Male Female

Name of Policy Holder:

Credit Card Type:

Card # Exp. Date:

Medication Dispensing

This form is used in setting up the infirmary. Please return to the camp office by June 10th.

Camper’s Full Name:

Camper’s name appears on prescription (if different):

Date of Birth: Full July August

If the infirmary has questions, they can reach me at:

Home Phone #: Cell Phone #:

Signature:

Medication #1

Name of Medicine:

Reason for medication:

Directions when to take (after meals): Breakfast Lunch Dinner Bedtime

Special Directions:

If a camper forgets to take medicine:

Please do not call – it's ok to miss a dose.

Please call my child to the infirmary. He or she cannot miss a dose.

Medication #2

Name of Medicine:

Reason for medication:

Directions when to take (after meals): Breakfast Lunch Dinner Bedtime

Special Directions:

If a camper forgets to take medicine:

Please do not call – it's ok to miss a dose.

Please call my child to the infirmary. He or she cannot miss a dose.

Medication #3

Name of Medicine:

Reason for medication:

Directions when to take (after meals): Breakfast Lunch Dinner Bedtime

Special Directions:

If a camper forgets to take medicine:

Please do not call – it's ok to miss a dose.

Please call my child to the infirmary. He or she cannot miss a dose.

J Drugs Pharmacy Form

Please make sure all information is legible. Thank you.

Please attach each prescription and mail directly to J Drugs, 1205 Avenue J, Brooklyn, NY 11230.

Full Name of Camper Date of Birth

Name of camper how it appears on insurance card / prescription:

Address

Parent Name Home Phone #

Parent Cell # Summer Contact #

Allergies

Name of Medicine Dosage

What is the reason for taking this medication?

When is this medication taken at home?

This medication is taken Daily As needed basis

Please indicate dates of camp attendance: July August Full Other

Payment (Visa or MasterCard only)

Name on card

Please circle one: Visa / MasterCard

Credit Card Number Exp Date: