Try the all-new QuickBooks Online for FREE.  No credit card required.

2010 Camper Packet for DEC Camp

Document Sample
2010 Camper Packet for DEC Camp Powered By Docstoc
					           New York State
           Department of Environmental Conservation           Dates will attend camp: from ___________to___________

                                                                                                                                                             Camper Name
           Environmental Education Camps 2010

Medical                                                        Privacy Notification
History for Campers, Volunteers & Staff                        Because this form asks for personal information, the

1. Campers must bring this completed form, Signed by           Personal Privacy Protection Law requires that you be
the parent and physician, to camp. Campers without a           given this notice. Information requested on this form is
completed form will not be permitted to attend camp.

                                                               pursuant of Public Health Law 225, §7-28. Information is
2. Please complete this form accurately and carefully. In      needed to alert camp administration to special medical
the event of an emergency, the information on this form is     needs of the camp population. It will be treated as confi-
crucial.                                                       dential medical information and will be given to
3. Pages 1 and 2 are to be completed by the parent/            appropriate medical service providers in case of an
guardian.                                                      emergency. This form will be filed under the
4. Pages 3 and 4 must be completed by a health care            Environmental Education Camp Record File maintained
provider.                                                      by the Camp Director of the appropriate camp.
5. Parent/guardian must sign and date the Authorization        FAILURE TO PROVIDE THIS INFORMATION WILL
for Health Care section at bottom of page 4.                   RESULT IN THE CAMPER NOT BEING ALLOWED TO
                                                               ATTEND CAMP.

Camper Information

Camper Name: _________________________________________________________________________________
                     First                      Middle                    Last
Gender: □ Male    □ Female      Birth Date ____________   Age on arrival at camp: ________

Home Address: _____________________________________________________________________________
                 Street Address                  City                 State       Zip Code

Emergency Information
Parent/guardian with legal custody to be contacted in case of illness or injury:

Name: ____________________________ Relationship to Camper: ________________

                                                                                                                                                             (For Camp Use) Cabin or Group____________________
Home Phone (____) ____________        Cell (____)_______________               Work (____)_______________

Home Address:______________________________________________________________________________
(If different from above)        Street            Address   City       State       Zip Code
Second parent/guardian or other emergency contact:

Name: ____________________________ Relationship to Camper: ________________

Home Phone: ( ___ ) _____________ Cell (____)_______________                   Work (____)_______________

Additional contact in event parent(s)/guardian(s) can not be reached:

Name(s): __________________________ Relationship to Camper: ________________

Home Phone: (___ ) _____________ Cell (____)_______________                 Work (____)_______________

Medical Insurance Information:
This camper is covered by family medical/hospital insurance              Yes     No

Insurance Company______________________________ Policy Number___________________________

                                                     Company Phone Number (____)___________________
Subscriber________________________________ InsurancePage 1
Medical History
Campers personal medical history and information must be filled out by the parent/guardian. For questions answered “yes”
explain in the area below the question. If there is not enough room, attached another piece of paper.

Allergies:      No known allergies
                This camper is allergic to: Food     Medicine      The environment (insect stings, hay fever, etc.)                                        Other
(Please describe below what the camper is allergic to and the reaction seen.)

Diet, Nutrition:       This camper eats a regular diet.                  This camper eats a regular vegetarian diet.
                       This camp eats a vegan diet.                      This camper has special food needs. (Please describe below.)

 Restrictions:     have reviewed the program and activities of the camp and feel the camper can participate without restrictions.
                   have reviewed the program and activities of the camp and feel the camper can participate with the following
restrictions or adaptations. (Please describe below.)

General Questions (Explain “yes” answers below)
Has/does camper:
1. Had any recent injury, illness or infectious disease?            yes / no         16. Ever had a problems with joints?                             yes / no
2. Had a chronic or recurring illness/condition?                    yes / no         17. Orthodontic, appliance being brought to camp?                yes / no
3. Ever been hospitalized?                                          yes / no         18. Have any skin problems?                                      yes / no
4. Ever had surgery?                                                Yes / no         19. Have diabetes?                                               yes / no
5. Have frequent headaches?                                         yes / no         20. Have asthma?                                                 yes / no
6. Ever had a head injury?                                          yes / no         21. Had mononucleosis in past 12 months?                         yes / no
7. Ever been knocked unconscious?                                   yes / no         22. Have problems with diarrhea/constipation?                    yes / no
                                                                                     23. For females: this camper knows about
8. Wear glasses, contacts or protective eye wear?                   yes / no             menstruation and/or has a normal menstrual
                                                                                         history.                                                     yes / no
9. Ever had frequent ear infections?                                yes / no         24. If female, have an abnormal menstrual
                                                                                         history?                                                     yes / no
10. Ever passed out during exercise?                                yes / no         25. Have history of bed-wetting?                                 yes / no
11. Ever been dizzy during or after exercise?                       yes / no         26. Have problems with sleepwalking?                             yes / no
12. Ever had seizures?                                              yes / no         27. Ever had emotional difficulties for which                    yes / no
13. Ever had chest pain during or after exercise?                   yes / no             professional help was sought?                                yes / no
14. Ever had high blood pressure?                                   yes / no         28. Ever had an eating disorder?                                 yes / no
15. Ever had back problems?                                         yes / no         29. Ever been diagnosed with a heart murmur?                     yes / no

Please explain any “yes” answers, noting the number of the questions. For more specific health conditions (i.e.
Diabetes mellitus, unstable or newly diagnosed asthma, seizure disorders) please provide more specific health
information from the physician regarding the condition.

Mental, Emotional, and Social Health:
Has the camper:
1. Ever been treated for attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)………….yes / no
2. Ever been treated for emotional or behavioral difficulties or an eating disorder?................................ .................yes / no
3. During the past 12 months, seen a professional to address mental/emotional health concern .............................yes / no
4. Had a significant life event that continues to affect the camper’s life?.....................................................................yes / no
  (history of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others)
Please explain “yes” answers in the space below, noting the number of the questions. The camp may contact you for
additional information

                                                                             Page 2
Medications/Standing Orders/Immunizations
Must be completed by a health care provder. “Medication” is any substance a person takes to maintain and/or improve
their health. This incudes vitamins and natural remedies. Any medication your child may need must be given to our
medical director in the original prescription bottle. This medicine can only be dispensed according to the doctor’s written
instructions. Be sure to provide enough of each medicine to last the entire time the camper will be at camp.

Medication:      This camper will not take any daily medications while attending camp.
                 This camper will take the following daily medications(s) while at camp:

 Name of medication When it is given               Dosage                How it is given     Comments
  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 (to be administered at the discretion of RN).
           Drug                 Dosage                  Schedule              Provider Order Comments     MD signature/

 Acetaminophen                   Per label            q 4hr prn for pain or       yes / No
 (Tylenol)                   instructions by           fever >_________
 Ibuprofen                       Per label            q 4hr prn for pain or       yes / No
                             instructions by           fever >_________
 Antihistamine/ allergy          Per label            q 4hr prn for pain or       yes / No
 medicine (Benadryl)         instructions by           fever >_________
 Calamine Lotion                 Per label              For insect bites,         yes / No
                               Instructions            poison ivy, itching

 Pseudoephedrine de-             Per label            q 4hr prn for pain or       yes / No
 congestant                  instructions by           fever >_________
 (Sudafed PE)                  age/weight
 Generic cough drops             Per label            For sore throats and        yes / No
                               Instructions                coughing

 Antibiotic cream               Per label           For avoiding infection in     yes / No
                               Instructions          cuts, and open sores

                                                               Page 3
 Pepto-Bismol             Per label instructions      For upset stomach,          yes / No
                             by age/weight            ingestion problems
Immunization History: Please provide the month and year for each immunization. Starred (*) immunizations must be current. Copies
of immunization forms from health-care providers or state or local government are acceptable. Please attach to this form.

          Immunization              Dose 1           Dose 2           Dose 3            Dose 4           Dose 5          Most Recent
                                   Month/Year       Month/Year       Month/Year        Month/Year       Month/Year       Dose Month/
  Diphtheria, Tentanus,
  Pertussis *
  (Dtap) or TdAP)
  Tetanus booster*
  (dT) or (Tdap)
  Mumps, Measles, Rubella*
  Haemophilus Influenza
   type B (HIB)
  Hepatitis B

  Hepatitis A

  Varicella (Chicken pox)
  □ Had chicken pox
  Meningococcal meningitis

   Tuberculosis (TB) test           Date:                   □ Negative         □ Positive

If your camper had NOT been fully immunized please sign the following statement: I understand and accept the risks to my
child from not being fully immunized.
Signature of Custodial
Parent/Guardian: ___________________________________________Date:____________________

Physicians Name (printed): ________________________________________________________________________

Signature of physician: ___________________________________________________________________________

Date_______________________________________________ Phone Number________________________________

Name of family Dentist/Orthodontist______________________ Phone Number _______________________________

 Parent/Guardian Authorization for Health Care:
 This health history 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 photocopy this form. 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.

 Signature of Custodial                              Page 4
 Parent/Guardian _____________________________________________________Date: _______________________
                                                                                           Form # 1

New York State Department of Environmental Conservation
Division of Public Affairs and Education
Bureau of Environmental Education, 2nd Floor
625 Broadway, Albany, New York 12233-4500
Phone: (518) 402-8014 • FAX: (518) 402-9036

         Custody/Guardian/Foster Care Information 2010

Camper Name: _______________________________________________

To ensure, to the best of our ability, the welfare and safety of all campers attending our camps,
please check the circumstance below that best applies to your child.

           A. Not involved in any custody, guardian or foster care arrangements
           B. Guardianship or Legal Custody
           C. Foster Care
           D. Court-Issued Sole or Joint Custody

If you checked B, C or D above, and there are special circumstances camp staff should be aware
of, please contact camps administrator Randy Caccia at 518-728-0891 or via email

Please list the names of those individuals who may, with your prior notification to the camp, pick
up your child:

Date: __________________________
Parent/Guardian’s signature: ___________________________________
Address: _____________________________________________________
Phone:_______________                      Email:_____________________
                                                                                              Form #2

Dear Parent/Guardian,
The information provided on this form will be kept confidential from other campers and will
only be shared with those staff members caring for your camper. Complete this form with
your camper, and please be as thorough and accurate as possible. Bring the form with you
to camp. Thank you!

Dear Counselor:
My name is ________________________________________________________________________
I will be attending camp on the following dates: ____________________________________________
My nickname is (if applicable) __________________________________________________________
My birth date: _________ Age: ___________ # of brothers: __________ # of sisters: __________
I have been to a camp before (circle one): Yes No
       If yes, for how long? ____________________ Was it an overnight camp? Yes No
I am looking forward to camp because __________________________________________________
I am concerned about going to camp because _____________________________________________
My interests and hobbies are __________________________________________________________
DEC staff can make my experience great by ______________________________________________
Some of my favorite foods are _________________________________________________________
Some foods I dislike are ______________________________________________________________
Describe any special family circumstances you would like us to know about: _____________________
Health and Safety (circle and describe):
I will be taking medication while at camp: Yes No
I have allergies: Yes No
Special medical concerns/needs: Yes        No
Please describe: ___________________________________________________________________
Do you have a history of sleepwalking? Yes      No
Is there any other information that you would like to share with our camp staff that would help make your
camp experience the best possible? (You may also describe any items marked above.) Please add a
separate sheet of paper if necessary. ____________________________________________________

The information above is correct, and I give permission for my camper’s medical record and needs to be
shared with the staff who are responsible for his/her care.

Parent/Legal Guardian Signature: __________________________________ Date: ____________
                                                                                                 Form #4
New York State Department of Environmental Conservation
Division of Public Affairs and Education, 2nd Floor
625 Broadway, Albany, New York 12233-4500
Phone: (518 ) 402-8014 • Fax: (518) 402-9036
                         (MUST SIGN AND BRING THIS FORM TO CAMP)

          Acknowledgment of Parent/Camper Handbook 2010
The Handbook has been provided to you to more clearly detail camp policies and requirements for all campers.
 These policies and procedures are designed for your safety and well being.
 I (parent name) _____________________________________________ have read/understand and agree to
adhere to the Camper/parent handbook policies and procedures including code of conduct, dress code and items
to bring and not to bring to camp, as described in the Parent/Camper handbook. My child and I understand that
inappropriate or unmanageable behavior may result in dismissal from camp. We further understand that camp
fees will not be reimbursed in the event of dismissal due to breaking the Code of Conduct or to illness. I agree
to make immediate arrangements for my camper to leave camp, if asked to do so by the Camp Director, Health
Director or Camp Administrator.

Camper’s Name__________________________ Camper’s Signature______________________

Parent/Guardian Signature _________________________________ Date__________________

                                      Model Consent 2010
        I CONSENT to the use of my name and/or my likeness for the purpose of advertising or trade
by the New York State Department of Environmental Conservation or anyone authorized by that
Department to act on its behalf. “My likeness” includes photograph, videotape recording, film or
artistic rendering of me, a recording of my voice, and/or reproductions of any of these. I agree that the
actual material involved, such as a photograph, negative, plate, video recording, film, or audio
recording is and shall continue to be the property of the New York State Department of Environmental
        I understand and agree that I will not be compensated in any way for the use of my name
and/or likeness by the New York State Department of Environmental Conservation. I also understand
that the New York State Department of Environmental Conservation may incur expenses in
connection with the recording or reproduction of my name and/or likeness, and that I am free from
any responsibility for these expenses.
        If more than one person signs this consent, each such person hereby agrees to the preceding
provisions. If the person who is being photographed, filmed, videotaped or recorded is under age 18,
his/her parent or guardian must sign below instead.
Note: If you do not wish to provide Model Consent, do not sign this section.

Camper’s Signature___________________________________________Date______________

Parent/Guardian’s Signature______________________________________________________

                                                                                                              Form # 3
New York State Department of Environmental Conservation
Division of Public Affairs and Education
Bureau of Environmental Education, 2nd Floor
625 Broadway, Albany, New York 12233-4500
Phone: (518) 402-8014 $ FAX: (518) 402-9036
                          Environmental Education Summer Camps
                               Permission to Shoot Form 2010

  To:        Parent(s)/Guardian(s)
  From:      Environmental Education Staff
  Subject:   Camp Season Permission for participation in New York State Sportsman
             Education Program
             (Hunter Safety Course)** OR the Shooting Sports Program

                        New York State Department of Environmental Conservation
                                       Division of Fish and Wildlife

                 New York State Sportsman Education Program (Hunter Safety Course)
                                   or the Shooting Sports Program
                                      PERMISSION TO SHOOT
                                 for Students Under 16 Years of Age

An optional program that your child may participate in at camp is the New York State Sportsman
Education Program (Hunter Safety Course), or the Shooting Sports Program. New York State
Sportsman Education Program is offered during all regular 12-14 year old weeks at all camps.
Campers must complete the home study material to participate in this course. Returnee week
campers may take Bowhunter education. Shooting sports program is offered at Pack Forest week 1-4
and may be offered some weeks at other camps, based on interest. To participate in either
program, you must complete the permission slip (below) and have your child bring it to camp.
If your child does not wish to take the program, completion of this form is not necessary. If he/she is
not sure if they want to take the program, we suggest that you complete the form just in case!

     I___________________________________________ the parent/guardian (circle one) of
                  (Please Print)

     Child=s Name____________________________________________________________
                                     (Please Print)

     Birth Date_______________                          Age________

     hereby give permission for him/her to possess a rifle, shotgun or pellet gun for the purpose of loading and
     firing under immediate supervision, guidance and instruction of a duly certified Sportsman Education Instructor
     and/or a Certified Ranger Instructor of the New York State Department of Environmental Conservation.


     Date:____________________ Telephone: (____)_____________________________

                                                                                                    Turn Over

Shared By: