Nature Adventures Summer Day Camp

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					                       Nature Adventures Summer Day Camp
                                     Health Form
                      To be filled out by Parents or Guardians

Child’s Last Name               _           First Name                       Birthdate _____
Parent/Guardian(s)                  ___________                                Phone      ____
Home Address                                   ______          City                   Zip ____
Business/Other Address                                           Phone              _________
Emergency Contact                                                 Phone             _________
Emergency Contact                                                 Phone             _________

                                       Health History
Surgery or serious illness (give condition & dates)                                   _________
                                                                                      _________
Chronic or recurring illness                                                          _________
Medications                                                                           _________
Other health problems                                                                      ____
                                                                                           ____
Any identified or suspected special needs? Please describe.                                ____
                                                                                      _________
Name of Dentist/Orthodontist                                __ Phone                       ____
Name of Family Physician                                    __ Phone                       ____
Do you carry family medical/hospital insurance? Yes No If so, please indicate:
      Carrier                                     Policy or group #                            ____

     Important – Must be completed by parent/guardian for attendance
Parent’s Authorization: This health history is correct so far as I know, and the person herein
described has permission to engage in all prescribed camp activities except as noted by me
or the examining physician.

I hereby give permission to the physician selected by the camp director to order x-rays,
routine tests, and treatment for the health of my child. In the event I cannot be reached in an
emergency, I hereby give permission to the physician selected by the camp director to
hospitalize, secure proper treatment for, and order injection, anesthesia, and/or surgery for
my child as named above.

Signature                                         Witness
Date

Form must be received at least one month prior to camp session. Return to:
Camp  South Shore Natural Science Center  P.O. Box 429  Norwell, MA 02061
Fax: 781-659-5924

                                                                        Other Side for Physician’s form
       To be filled out by a Physician or other Health Care Provider
           (or attach a current, signed physical examination form)
                               Medical History – Give Dates
Chicken Pox ___________ German Measles ________ Mumps ______________ Strep Throat __________
Congenital Anomaly _____ Heart Disease __________ Operations ___________ Tonsillitis ______________
Convulsions ___________ Hernia ________________ Poliomyelitis __________ Tuberculosis ___________
Diabetes ______________ Kidney Disease _________ Rheumatic Fever ______ Whooping Cough _______
Ear Infections __________ Measles _______________ Scarlet Fever _________ Other ________________
Encephalitis ___________ Meningitis ______________

                                    Physical Examination
Date ___________    Name _______________________________________________
Age _______ BP ______/______ Pulse _____ Height _______ Weight _______

IMMUNIZATION         Date           IMMUNIZATION         Date           IMMUNIZATION             Date
DPT                  _______        POLIO                _______        MMR (combined)           ____
Diphtheria           _______        Oral                 _______        Tetanus toxoid           ____
  Tetanus            _______        Trivalent            _______        Other                    ____
  Pertussis          _______        TOPV                 _______

Td                 _______          Measles              _______        SPECIAL TESTS
Tetanus Diphtheria _______          Mumps                _______        Tuberculin Test          ____
Adult Type         _______          Rubella              _______        Lead Test                ____

Eyes________________ Lungs _______________ Ears _____________ Nose _______
Glasses______________ Abdomen ____________ Hernia ___________ Throat _______
Heart________________ Extremities ___________ Posture __________ Skin _________
Genitalia______________

General Appraisal ___________________________________________________________
Allergies ___________________________________________________________________
Recommendations and restrictions while in camp
Diet ______________________________________________________________________
Medications ________________________________________________________________
Activity Limitations ___________________________________________________________
Other _____________________________________________________________________

I have examined and reviewed the person herein described and have reviewed the health
history. It is my opinion that this camper is physically able to engage in camp activities,
except as noted above.

Signature _____________________________________   Date _____________________
Printed Name __________________________________   Phone ____________________
Address ___________________________________________________________________

                                                                             Other side for Parent’s Form