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Health Form

Health Form

 

Health Form 
This form is mandatory for all campers and staff of Camp Gan Israel. No child will be allowed to participate in camp activities without this form. All fields must be entered, if not relevant please write N/A.

Please complete a separate form for each child.

You should receive a copy of your submission by email.  If you do not receive a confirmation, please refill out this form or contact our office for assistance.

Campers Last Name   First Name  
Date of Birth    Emergency Contact  
Emergency Contact Phone    Relationship  
Pediatrician Name Phone
Insurance Provider Policy #

Allergies and Sensitivities (Including insect bites and stings)
My child has an allergy My child does not have an allergy 
Please list all allergies and describe the reaction and severity 

Medication 
My child is currently taking medication My child is not currently taking any medication 
Please list all medications being taken with the reason 

Health History 
(Check all that apply. Note dates and add comments in the notes section when appropriate.) 

Frequent Ear Infections 
 Seizures or Convulsions 
 Hypertension 
 Mononucleosis 
 Asthma, Wheezing or Shortness of breath 
 Diabetes
 Measles 
 Mumps 
 Bleeding/Clotting Disorders 
 Seasonal Allergies 
 Other Condition, Illness or Injury 
 None of the above

Notes 
Please add any relevant information about the above items in the health history. 

Other 
Please list operations / injuries / disabilities / recurring illnesses (include dates), or any fears, special diets or needs, learning disabilities, behavioral issues, etc. of which we should be aware 

Immunization history 
All required immunizations are up to date 
I do not give immunizations for religious or other reasons

Last tetanus shot (date): 

Non-prescription Medications
The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. 
Please check off those your child should not be given.

 Acetaminophen (Tylenol) 
 Ibuprofen (Advil, Motrin) 
 Antibiotic cream 
 Antihistamine/allergy medicine 
 Dimenhydrinate (Dramamine)
 Calamine lotion 
 Aloe 
 Diphenhydramine antihistamine/allergy medicine (Benadryl) 

Over the Counter Medication

From the above list, I give permission for authorized Camp Gan Israel of Simcha Monica personnel to dispense any of the non-selected medication to my child/ren, if they deem it is necessary, without notifying me first. Dosages will be according to the directions on the label. I will be informed of any medication given to my child.  I understand that Camp Gan Israel staff will try to reach me before administering the above medications. 

 I allow     Do not allow

Restrictions 
I have reviewed the program and activities and my child can participate without restrictions. 
I have reviewed the program and activities and my child can participate with the following restrictions. 

The health history that I have provided is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations.

If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to print this information. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.

Please provide your (guardian) name as your digital signature 
Signature  Date  
Email Address 

 

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