Summer Camp Health Form Page 2
ADVERTISEMENT
1
2
3S
III – M
ECTION
EDICATIONS
Will camper be taking medications while at camp?
Yes
No
(Medications include prescription, over‐the‐counter,
vitamins, inhalers, etc.)
If camper will be taking medications while at camp, it is Wisconsin state law to secure your consent for
medication distribution and for the use of medical devices. The medication can be self‐administered (if
over 18) or administered by Health Services Staff. Please list all (prescription and non‐prescription).
Include the medication name, prescribing physician, physicians’ phone number, and the dosage
instructions. Use an additional sheet if needed. When you check‐in at camp, please provide all medications
(in their original packaging that identifies the prescribing physician (if prescription drug), the name of the
medication, the dosage, and frequency of administration.
______ I want the medication or medical devices self‐administered. (Age 18 and above only.)
______ I want the medication or medical device administered by the Health Services Staff. However, a
limited amount of medication for life threatening conditions should be carried by my
son/daughter/ward. (i.e. bee sting kits, inhalers)
Medication____________________ Dosage_________________ Take at what times__________________
Reason for Taking________________________________________________________________________
Prescribing Physician____________________________________ Phone____________________________
Medication____________________ Dosage_________________ Take at what times__________________
Reason for Taking________________________________________________________________________
Prescribing Physician____________________________________ Phone____________________________
Medication____________________ Dosage_________________ Take at what times__________________
Reason for Taking________________________________________________________________________
Prescribing Physician____________________________________ Phone____________________________
S
IV – A
ECTION
LLERGIES
Camper does not have any Allergies
Camper is allergic to
1. Hay Fever
2. Poison Ivy/Oak
3. Insect Stings
4. Food
5. Penicillin
6. Other Drugs
7. Other
List allergy. Describe reaction and treatment
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
501) 821‐3093 •
S
V – I
ECTION
MMUNIZATIONS
Please record the month and year of immunizations. If you do not know the dates or whether camper
has had certain immunizations, simply leave blank.
DPT (Diphtheria, Pertussis, Tetanus).....
________
HIB (Haemophilus Influenza B)...... _______
Tetanus Booster ...................................
________
Tuberculin Test .............................. _______
Polio......................................................
________
Varicella (Chicken Pox)................... _______
MMR (Measles, Mumps, Rubella)............. ________
Hepatitis B ..................................... _______
Page 2 of 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical