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Child’s Health History Form
This 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. AUTHORIZATION FOR TREATMENT: I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests, treatment, and
necessary transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the
camp director to secure and administer treatment, including hospitalization, for my child as named below. The completed form may be photocopied
for trips out of camp. Please return this form to the CCUSA office in your home country by May 1st, or fax it directly to the camp office at
least 2 weeks prior to your child’s start date.
Signature of Parent or Guardian ____________________________________________________ Date __________________ Session:________________ Child’s Name ________________________________________________________ Birth Date ____________________________ Sex: HEALTH HISTORY
List any surgeries, serious injuries, or fractures (include dates and current status): ____________________________________________________________ ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ Attention Deficit Disorder or behavioral problems _________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ Has the child ever been under a professional’s care for emotional, psychological or learning difficulties? describe _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ Check all that apply and give approximate date of: Diseases
Allergies
Name of dentist ______________________________________________________________________ Phone # _______________________________________ Name of family physician ______________________________________________________________ Phone # _______________________________________ FEMALE CAMPERS:
Has child menstruated? ____________________ If not, has she been told about it? ___________________________________________________________ MEDICATIONS BEING TAKEN—PARENT COMPLETE THIS SECTION
Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely. The child should bring enough medication to last
the entire time at camp. Keep it in the original packaging that identifies the prescribing physician (if a prescription drug), the name of the medication,
the dosage and the frequency of administration in English. All medications will be stored in the camp medical facility.
Child takes NO medications on a routine basis. Med #1 ______________________________________________ Dosage ____________________________ Specific times taken each day ____________ Reason for taking _____________________________________ Med #2 ______________________________________________ Dosage ____________________________ Specific times taken each day ____________ Reason for taking _____________________________________ Med #3 ______________________________________________ Dosage ____________________________ Specific times taken each day ____________ Reason for taking _____________________________________ Attach additional sheet for more medications.
IMMUNIZATION HISTORY
Please record the approximate month and year of immunizations.
Vaccines Date of 1st immunization
Date of last immunization
DPT series (Diphtheria, Pertussis, Tetanus) RECOMMENDATIONS AND RESTRICTIONS WHILE AT CAMP
Any treatment to be continued at camp? _______________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ If other, please explain ________________________________________________________________________________________________________________ Additional Health Information __________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ Does the applicant have any special dietary requirements? _______________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ FOR CAMP INFIRMARY USE ONLY
Camp Nurse’s Comments _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________

Source: http://mybestcamp.ru/Uploads/Data/cca_10_hhf.pdf