CampWaiver

Medical Information Form & Waiver

First Name

Last Name

MEDICATIONS BEING TAKEN

Please list ALL medications (including over the counter or non-prescription drugs) taken routinely. Use of any medication is solely the responsibility of the camper and/or his/her parents/guardian while away from Club property. Please note: Nassau Racquet & Tennis Club employees will not administer any medications, nor will any medications be stored on the premises.

This person takes NO medications on a routine basis.

This person DOES take medications.

Med #1

Dosage

At Specific Time(s)

Reason

Med #2

Dosage

At Specific Time(s)

Reason

Med #3

Dosage

At Specific Time(s)

Reason

RESTRICTIONS

The following restrictions apply to this individual

Does NOT eat:

Red meat

Pork

Dairy

Poultry

Seafood

Eggs

Nuts

Other

ALLERGIES

Explain any restrictions to ACTIVITY (e.g. what cannot be done, what adaptations or limitations are necessary)

GENERAL QUESTIONS

(Explain “yes” answers below) Has/does the participant:

Had any recent injury, illness, or infectious disease?

Yes

Have a chronic or recurring illness/condition?

Yes

Ever been hospitalized?

Yes

Ever had surgery?

Yes

Ever had a head injury?

Yes

Ever been knocked unconscious?

Yes

Wear glasses, contacts or protective eye wear?

Yes

Ever had frequent ear infections?

Yes

Ever passed out during or after exercise?

Yes

Ever been dizzy during or after exercise?

Yes

Ever had seizures?

Yes

Ever had chest pain during or after exercise?

Yes

Ever had high blood pressure?

Yes

Ever had back problems?

Yes

Ever had problems with joints (e.g., knees, ankles)?

Yes

Use an orthodontic appliance at camp?

Yes

Have any skin problems (rash, itching, acne)?

Yes

Have diabetes?

Yes

Have asthma?

Yes

Had mononucleosis in the past 12 months?

Yes

Had problems with diarrhea/constipation?

Yes

Have problems with sleepwalking?

Yes

If female, have an abnormal menstrual history?

Yes

Have a history of bed-wetting?

Yes

Ever had an eating disorder?

Yes

Been treated for emotional issues by a professional?

Yes

Ever been diagnosed with a heart murmur?

Yes

Please explain any “yes: answers, noting number of question(s):

Which of the following diseases has the participant had?

Measles

Chicken Pox

German measles

Mumps

Hepatitis A

Hepatitis B

Hepatitis C

Immunization Dates

Please give all dates of immunization below or drop off immunization form from your child's doctor at the Club (please note - immunization records are required before your child may attend camp):

DTP (MM/YY)

TD (tetanus/diphtheria) (MM/YY)

or Measles

or Mumps

or Rubella

Heamophilus influenza B (MM/YY)

Hepatitis B (MM/YY)

Vericella (chicken pox) (MM/YY)

TB Mantoux Test

Date of last test

Result

Please provide any additional information about the participant’s behavior and physical, emotional, or mental health about which the camp should be aware:

Name of family physician:

Phone

Address

EMERGENCY CONTACT #1

EMERGENCY PHONE #1

EMERGENCY CONTACT #2

EMERGENCY PHONE #2

TERMS OF ACCEPTANCE and SIGNATURE

Finally, I understand there is no provision for medication administration at Camp.

Signature Parent/Legal Guardian

Date

Above named Parent or Guardian agrees to the Liability Waiver with this electronic signature.

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the terms, conditions and liability waiver required for all program participants.

To confirm your request, please tick the box below:

Club Currently Open

Medical Information Form & Waiver

MEDICATIONS BEING TAKEN

RESTRICTIONS

Does NOT eat:

GENERAL QUESTIONS

Which of the following diseases has the participant had?

Immunization Dates

DTP (MM/YY)

TD (tetanus/diphtheria) (MM/YY)

Tetanus (MM/YY)

Polio (MM/YY)

MMR (MM/YY)

or Measles

or Mumps

or Rubella

Heamophilus influenza B (MM/YY)

Hepatitis B (MM/YY)

Vericella (chicken pox) (MM/YY)

TB Mantoux Test

TERMS OF ACCEPTANCE and SIGNATURE