Health Record Form For Children In Day Camps , Afterschool And Youth Centers
ADVERTISEMENT
1
2HEALTH RECORD FOR CHILDREN IN DAY CAMPS & AFTERSCHOOL & YOUTH CENTERS
(This side to be filled in by parent before presentation to physician)
NAME OF PROGRAM
M ❑
F ❑
/
/
CHILD'S LAST NAME
FIRST NAME
BIRTHDATE
SEX
Home Address:
Phone:
Parent or Guardian:
Phone:
Place of Employment: Father (Guardian)
Phone:
Mother (Guardian)
Phone:
In case of emergency, notify:
Phone:
If Parent, Guardian are not available in an emergency, notify:
1.
Phone:
or 2.
Phone:
Important: Has this camper been exposed to any communicable disease during the three weeks prior to camp attendance:
Yes ❑ No ❑
(If yes, state type of exposure:
)
HEALTH HISTORY: (Check box if child has had afflictions, give appropriate dates)
Allergies
❑
❑
Rheumatic Fever
Hay Fever
❑
❑
Seizures
Poison Ivy, etc.
❑
❑
Diabetes
Insect Stings
❑
❑
Asthma
Penicillin
❑
❑
Chicken Pox
Other Drugs
❑
Food
Other Past Illnesses
Operations or Serious Injuries (Dates)
Hospitalization (Dates)
Chronic or Recurring Illness
Any specific activities to be encouraged?
Conditions that require activity to be restricted?
Permission for all program activities unless otherwise noted by Dr.
Appliance worn (glasses, contacts, etc.)
Medication taken
Suggestion from Parent/Guardian
CONSENT FOR EMERGENCY MEDICAL TREATMENT
I do hereby give authority to the Day Camp and Year Round Afterschool and Youth Center Program staff to obtain necessary
emergency medical treatment for my child with the understanding that the family will be notified as soon as possible.
Relationship
Signature
Date
Tel.#
Department of Health and Mental Hygiene — The City of New York — Bureau of Food Safety and Community Sanitation
DCR 7 (Rev. 2/04)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical