Camp Judah Camp Judah Health Form Camp Hickory Hill
This form MUST be accurately completed by all campers or camp staff members and submitted with a registration form. Part One should be filled out by the parents of campers or staff applicants under the age of 19. Part Two must be filled out by the personal care physician, physician’s assistant or certified nurse practitioner of any camper or of any staff applicant under the age of 19. Adult staff applicants may fill out both parts of this form themselves. Camp Judah is located on a hillside and will be physically challenging, if your child’s mobility is limited or health is otherwise impaired. Please be certain your child is in good health and up to the physical demands upon arrival at camp. We will be unable to safely accommodate some types of medical conditions. Please contact the camp director at (585) 786 - 2969 if you have questions regarding this.
Please be advised that we are subject to New York State laws and require the EXACT information requested. Failure to document this information will result in delay of registration of your camper. Name________________________________________ Gender____________Date of Birth____________________ Address__________________________________City____________________State__________Zip____________ Home Phone: _____________________________ PERSON TO CONTACT IN CASE OF EMERGENCY:
1. Name____________________________Relationship to camper____________________Phone _________________ 2. Name____________________________Relationship to camper____________________Phone _________________
Health Insurance Information: Carrier________________________________________________Type__________________________________ Policy # ___________________________________________ Phone # ( )________________________ In Whose Name? _____________________________________________________________________________ IMMUNIZATIONS - We must have dates (month/year). It is not sufficient to write “Up-to-date.” It is sufficient to
attach a copy of immunizations provided by the camper’s medical care provider. If no immunizations have been given, we must have documentation attached. DPT Series _____ _____ _____ _____ _____ Tetanus ________ Polio OPV (Sabin) _____ _____ _____ _____ German Measles _____ _____ Measles Vaccine (live)_____ _____ Mumps _____ _____ Hepatitis B _____ _____ TB Test (latest) _____ Results _____ Hib _____ _____ _____ _____ Varicella Chicken Pox _____ ____
Health History: Diabetes ________ Rheumatic Fever _______ Bedwetting _______ Ear Infection ________ Convulsions ________ Sleep Walking _________ Communicable or contagious illnesses _______________ Other ___________________________________________________________________________________
Please share any further comments regarding your child’s social, emotional, and/or psychological well-being that would be important for the staff to be aware of. This information will only be shared with the pastors, directors and your child’s specific counselor for the safety and well-being of the campers.___________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Parent’s Authorization (must be signed): This health form is correct so far as I know, and the person herein described has permission to engage in all camp activities, except as noted on this form. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child as named above. I also authorize the camp nurse to administer treatment as per standing order protocol and to administer any medications prescribed by his/her physician as listed on this form. Parent/Guardian Signature Relationship Date
Part Two must be filled out by the personal care physician, physician’s assistant or certified nurse practitioner of any camper or of any staff applicant under the age of 19. Dear Health Care Provider,
Your patient - ___________________________ is applying to attend a week of
summer camp. There will be a Camp Health Director at camp during the week to provide for any health care needs of all campers. In addition to the use of basic medical supplies to provide for general health care, the Camp Health Director is able to consult with an area M.D., P.A. or C.N.P. should the need arise. Your office and the camper’s parents would also be contacted should the situation warrant. There is a local hospital approximately 15 miles away where emergency services are available at all times. Please review the following general prn orders, deleting (by crossing out and initialing) or adding any additional OTC or prescription medications. Your signature at the bottom will authorize the Camp Health Director to administer treatment should your patient require general health care during his/her week at camp. (The Camp Health Director meets all certification standards according to the New York State Sanitary Code for Overnight Camps. He or she is typically an RN, but may be an EMT, LPN, MD, PA or CNP.)
Orders for Camp Nursing Care Hay Fever Allergy Symptoms: Benadryl q 4-6 hours prn according to directions on bottle for age/weight of child Or Loratidine (Claritin) 10 mg. q 24 hours prn for adults and children over 6 years of age. ___________________________________________________________________________ Headache/Mild Pain: Tylenol q 4-6 hours per dosing instruction prn OR Ibuprofen per dosing instruction. _______________________________________________________________________ _________________________________________________________________________________ Bee Sting without reaction: Remove stinger, apply ice. Give Tylenol prn for pain per dosing instruction, Benadryl, prn for itching per dosing instruction. Observe for signs and symptoms of swelling which continues to spread more than 24 hours or hives develop – in which case: contact outside medical professional. If there are multiple bee stings (8-10) contact primary physician and/or take child to ER._____________________________________________________________ Bee Sting WITH anaphylactic reaction (or ANY ANAPHYLACTIC REACTION): Give epinephrine (bee sting kit) and call 911 immediately. ________________________________________________ ________________________________________________________________________________ Skin Abrasions/Lacerations: Cleanse with soap and water or saline. Use Hydrogen Peroxide. Apply triple antibiotic ointment and a dry sterile dressing. Watch for infection and uncontrolled bleeding. ________________________________________________________________________________ Limb trauma injuries: Apply ice. Tylenol or Ibuprofen per dosing instruction prn for pain. ________________________________________________________________________________ Contact Dermatitis/Skin Allergies: Apply hydrocortisone cream t.i.d. per dosing instruction. Cool soaks. Avoid contact with allergen. ___________________________________________________ Poison Ivy: Wash with cool water repeatedly, discarding all clothes that may have “oil” on them. Apply hydrocortisone tid and give Benadryl per dosing instruction to control itching. If the affected area is greater than 1 cm on the face or near the eyes, call primary care or consulting physician. _______________________________________________________________________________ Poisoning: Call Poison Control. 1-800-888-7655 Nausea and Vomiting: Assess for dehydration. Offer small amounts of clear liquids less than one ounce at a time. If vomiting continues for more than 4 – 8 hours call primary care or consulting physician or send child home. ________________________________________________________ Diarrhea: Assess for dehydration, give clear liquids. Tums may be given for acid indigestion or “over eating.” ___________________________________________________________________________ Fungal-type Skin infections: Apply Clotrimazole cream to the affected area, bid per dosing instruction.________________________________________________________________________ Sore Throat: Tylenol prn as per dosing instruction on package. Sore throat spray and lozenges, prn per dosing instruction. Give fluids. If fever persists with sore throat call primary care physician. Persistent Cough: Robitussin (or generic form) prn q 4 – 6 hours per dosing instruction.___________ Cold/Sinus symptoms: Actifed or Dimetapp q 4 – 6 hours, prn. per dosing instruction. _________________________________________________________________________________ Fever/Flu symptoms: Tylenol and or ibuprofen, prn per dosing instruction. Treat other symptoms, e.g. runny nose with Dimetapp or Actifed or cough with Robitussin as per dosing instruction on package. If fever persists, call primary care physician and/or send the child home.__________________________ _________________________________________________________________________________ Animal Bites: Cleanse area with soap and water, running over wound. Apply triple antibiotic ointment and dry sterile dressing. Watch for signs and symptoms of spreading infection in next 24 hours. PRIMARY CONCERN: RABIES STATUS of animal. Call Wyoming County Community Hospital (786-2233), consulting or primary care physician. _________________________________________ Burns: (including sunburn): Apply cool water. Tylenol or Ibuprofen prn, for pain per dosing instruction. _________________________________________ _______________________________________
ADDITIONAL PRN MEDICATIONS THAT MAY BE GIVEN ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ MEDICATION RESTRICTIONS: ________________________________________________________________________________________ ________________________________________________________________________________________
List all Allergies: Food____________________________ Medications_____________________Hay Fever____________ Insect bites/stings_________________ Other________________________________________________ List any food or activity restrictions: _________________________________________________________ ______________________________________________________________________________________ Camper’s name: ____________________________________________Date:________________________
Please list ALL medications (including over the counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire time at camp. IMPORTANT!!Keep all medication in the original and current packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration. Medication Specific times taken
Camper may keep inhaler with him at all times. (Please check if applies.) Attach additional pages for more medications.
Date of last physical exam: ____________________ Additional information for the health care staff at Camp Judah pertinent to this registrant: ______________________________________________________________________________________ ______________________________________________________________________________________ In my opinion, the above registrant isis not able to participate in an active camp program.
*Signature of Licensed Medical Personnel (MD, PA, or CNP ONLY) Date (*This signature is required for any camper or for any staff member under the age of 19.) Printed Name of MD, PA or CNP___________________________ License #________________________
Address:______________________________________________ Phone #_________________________ Camper’s name: ____________________________________________Date:________________________ Please submit completed health form to Camp Judah, 2444 North Main Street, Warsaw, NY 14569
Navaratri - Day 4 - Meenakshi Devi - 1/Oct/2011 refrain: s¡mahit¡ ¿ivatanug¡ s¡ ka¸aka¸ag¡ stanzas: 1) k°mala r£p¡ sumadhura c¡p¡ calan® 3) r¡gasr°ta svinyanu g¢t¡ saccid¡nand° Meaning: Refrain: She has a worshipful stature and so everyone worships her. She is pleased with Sama Veda music. She is the better half of Shiva. She resides in every atom. She resides in all th
De cualquier modo, habrá que observar a cada individuo en una amplia variedadde situaciones sociales (ej: en clase, reuniones de scouts, el parque, juegos con los her-manos), para evaluar las habilidades que posee en diferentes momentos. Las actividades pedagógicas más eficaces han resultado ser el juego de roles y el deimitación, seguidos por otros juegos, el adiestramiento y relajación.