Microsoft word - 2008 medical and insurance information.doc

Grays Harbor Panhandle 4-H Camp Medical and Insurance Information
Name of 4-H member______________________________ Phone ______________ Birth date__________________
Insurance Co. Name & Address _________________________________________Policy # ____________________
REQUIRED INFORMATION FOR MEDICAL TREATMENT:

Age ______ Height ______ Weight ______ Male ______ Female ______ Date of last tetanus shot _______________
Doctor’s Name _____________________________ City _____________________ Phone # ____________________
Dentist’s Name ______________________________ City _____________________ Phone # ___________________
Does your child take any special medication(s) at home? Name of drug(s)?___________________________________
________________________________________________________________________________________________
Place a check mark next to any medical condition(s) your child may have, and relate any pertinent information
about the condition.
ALLERGIES: Bee stings ___________ Drugs ___________Pollen___________Food___________Other__________
Describe reactions________________________________________________________________________________
_____ADD/ADHD ________________________________________________________________
_____ Chronic earaches ________________________________________________________________
_____ Diabetes _________________________________________________________________
_____ Asthma _________________________________________________________________
_____ Hearing loss/visual problems ________________________________________________________________
_____ Nosebleeds _________________________________________________________________
_____ Physical disabilities ________________________________________________________________
_____ Bed wetting/sleep walking ________________________________________________________________
_____ Other medical problems _________________________________________________________________
I hereby authorize and give my consent to the authorities of the Grays Harbor 4-H Panhandle Camp to obtain
emergency medical treatment for ______________________________________________________.
Name of Camper
I also authorize medical authorities to perform upon or administer necessary medical or surgical treatment to the
above camper. Camp authorities are not excused from attempting to contact me before relying upon this statement.
I understand that the information listed above may be shared with other camp personnel on a need to know basis to
facilitate the camp staff in providing a safe environment for my son or daughter.
____________________________________________________ ________________________________________
Parent/Guardian Date
Continue
Grays Harbor Panhandle 4-H Camp Medication Release Form
Camper Name ________________________________ Phone # _________________________
While your child is at camp, the medical staff may need to administer one of the following “over-the-counter”
medications to your child. Please check “yes” or “no” next to each medication. Those that are marked “no” or
those medications that have no check mark next to them will not be given to your child.
ORAL MEDICATIONS

Acetaminophen (Tylenol) yes _____ no _____
Ibuprofen
Diphenhydramine (Benadryl) yes _____ no _____ Cough syrup or drops
TOPICAL MEDICATIONS

Camphophenique
Most medications, ointments, or creams are generic brands. If there are any types of medications, ointments or creams that your child is allergic to, please list them here:_____________________________________________ ******INSTRUCTIONS FOR MEDICATIONS BROUGHT TO CAMP******
1. All prescription drugs MUST be brought to camp in the container in which they were issued with medical
orders and Physician’s name intact. No medications other than those prescribed by a physician should be
brought to camp.
2. Only the exact amount of medication required for your stay is to be brought to camp.
3. All medications must be given to the camp nurse upon arrival and picked up at departure.

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In event of emergency: Home # ____________ Work# _____________ Cell # ___________ Pager # __________
Emergency contact person(s) ____________________________________________________________________ Parent or guardian signature ________________________________________________ Date ________________

Source: http://graysharbor.wsu.edu/4-H/2008MEDICALANDINSURANCEINFORMATION.pdf.pdf