Page 1 CAMP MEDUSA 2006 CAMPER HEALTH FORM Name______________________________ Age_____ Sex ___ Parent(s)/Guardian(s) __________________________________________________ Address_____________________________________ Work Address ___________________________________ ___________________________________ Phone (____) ______________________________ Work Phone (____ ) ______________________________ If parent/guardian cannot be reached in an emergency,                         contact: 1. Name _______________________________ Address _______________________________ ________________________________________ ______________________________________ Phone (____ ) ________________                                                      Work Address ____________________________________ __________________________________________ Work Phone (____ ) _____________________ 2. Name _______________________________ Address _______________________________ ________________________________________ ______________________________________ Phone (____ ) ___________________________________ Work Address ____________________________________ __________________________________________ Work Phone (____ ) _____________________ Doctor's Name __________________________ Phone (____)___________________________________ Date of: last physical exam _________________ Date of last Tetanus booster _________________________ DO YOU HAVE HEALTH INSURANCE?     YES        NO If no, we will not exclude you from camp.                                                      If yes, the following information is required: Name of Insurance ________________________________________________ Number _________________________________________ For girls only: Has your daughter begun her menstruation cycle?                                      yes, are there any problems? _________________________________________________ If no, has the cycle been explained to her? _______________________________________ Dates if immunizations: (The Health Department requires dates,                   and we will have to return your registration to you, if you do not include them.) DPT series _______________________ Tetanus Booster _______________________ MMR ___________________________ Chicken Pox __________________________ Haemophilus influenza type b ______________________ Hepatitis b _______________________ NOTE: The Health Department does not require immunizations. Knowledge about allergies or chronic health conditions will not  be used to exclude anyone from camp, but it is in your young                  person's best interests that we be aware of any health problems                      or difficulties that might arise.

Page 2 Does your young person have problems with:                                               Ears ________ Heart ___________                                                         Sleeping ____________Fainting ______________                                  Behavior _____________ Diabetes __________                                      Bed wetting ___________________                                         Convulsions/Seizures _______________                                                 Asthma ________________ Other ___________ Does your young person have any allergies to:                                              Poison Ivy/Oak _________   Hay Fever ________                            Insect Bites/Stings _________     Drugs _____________                        Foods __________________       Other   __________________ Does your young person have permission to swim?  YES__ NO_ Does your young person regularly take medications? ___                            If yes, please identify______________________________                                            If your child needs to have any medication during camp,                            please bring it in its original container with the dosage                      instructions. Label it clearly: it will be given to the nurse                            at registration. The nurse locks all medications (prescription                      or over the counter) in the nurse's cabin and, throughout                             the session, makes sure that the camper takes the medication                       at the proper time. Are there any family circumstances (recent problems or deaths)               of which we should be aware in order to help make your young             person's time at camp a positive growing experience? _________________________________________________ ________________________________________________                 Has your young person had any serious operations or injuries? _________________________________________________ Does your young person have any physical restrictions? _________________________________________________ Does your young person have any emotional or behavioral                  problems? _________________________________________________ Does your young person have any learning disabilities or                      problems at school? _________________________________________________ Is there anything else we should know about your                                    young person? _________________________________________________ _________________________________________________ PARENT/GUARDIAN AUTHORIZATION In an emergency, when neither of the contact people on this application can be reached, I hereby authorize the Dean and/or Health Care Staff and/or Counseling Staff to take whatever action is deemed necessary for my young person's best interests. Parent/Guardian Signature ______________________________________ Date ____________________________