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D14-h.tamu.edu

MEDICAL INFORMATION FOR YOUTH PARTICIPANTS
INSTRUCTIONS: Complete the entire form and return to your County Agent. This form will be turned in with any medication you bring, both
prescription and non-prescription, to the health room upon your arrival. The information on this form is gathered only to assist us in identifying
appropriate care for your child. Any changes to this form should be provided to the camp health care provider upon the participant’s arrival in camp.
Provide complete information so that we can be aware of your child’s needs.
District ______ County________________________________ Cam per’s Nam e ____________________________________
Address _____________________________________ Parent or Guardian Nam e __________________________________
Daytim e Phone (_____)_______________
Address_____________________________________ Evening Phone (_____)_______________
Cell Phone
EMERGENCY CONTACTS: (if parent or guardian cannot be reached)
Nam e ________________________ Daytim e Phone (_____)_____________ Evening Phone (_____)_____________ Nam e ________________________ Daytim e Phone (_____)_____________ Evening Phone (_____)_____________ Nam e of Fam ily Physician: ________________________________________ Phone: (_____) ___________________ Medical Insurance Carrier: ________________________________________ Policy Num ber:___________________ ACTIVITY RESTRICTIONS:
Is there any reason to restrict full activity, including hiking, swim m ing or other strenuous play? ____Yes ____No
IF YES, describe in detail:_________________________________________________________________________
___________________________________________________________________(Use a separate page if needed.) MEDICATIONS: – Please list ALL medications, including over-the-counter or nonprescription drugs and
supplem ents. Send enough m edication to last the entire tim e at cam p. Keep all m edications in the original packaging or
bottle that identifies the prescribing physician, nam e of m edication, dosage and frequency. Use an additional sheet if
necessary.
Med # 1 nam e________________________________reason for taking_____________________________________ Med # 2 nam e________________________________reason for taking_____________________________________ Med # 3 nam e________________________________reason for taking_____________________________________ Med # 4 nam e________________________________reason for taking_____________________________________ MEDICATION ALLERGIES: – Please list ALL medications, including over-the-counter or nonprescription drugs
and supplem ents your child is allergic to. Use an additional sheet if necessary.
Med # 1 nam e________________________________ Med # 2 nam e______________________________________ Med # 3 nam e________________________________ Med # 4 nam e______________________________________ PLEASE CHECK “over-the-counter” medication(s) which camp personnel may administer as deemed necessary:
____ Ibuprofen (Motrin) ____ Pepto Bism ol ____ Any As Needed
NO, DO NOT ADMINISTER ANY “over-the-counter” medications to my child.
_________PLEASE INITIAL.
IMMUNIZATION HISTORY (MANDATORY) Please give DATE OF LATEST IMMUNIZATION for:
________TB Mantoux Test - Result: ___Positive HEALTH HISTORY: (Please check any of the following that apply)
_______
Other________________________________________________________________________________ ALLERGIES: (Please Check any of the following that apply)
____Other (please list) ___________________________ OPERATIONS OR SERIOUS INJURIES: (List along with approximate date): __________________________
________________________________________________________________________________________________ ____________________________________________________________________________________________ CHRONIC OR RECURRING ILLNESS:________________________________________________________
______________________________________________________________________________________________ ______________________________________________________________________________________________ ANY OTHER INFORMATION: ________________________________________________________________
______________________________________________________________________________________________ ______________________________________________________________________________________________ PLEASE ATTACH AN ADDITIONAL SHEET if necessary to provide any additional medical information or
additional inform ation about the participant’s behavior and physical, em otional or m ental health about which the cam p ____ADDITIONAL INFORMATION ATTACHED
____NO ADDITIONAL INFORMATION
PERM ISSION TO PROVIDE NECESSARY TREATM ENT OR EM ERGENCY CARE
I hereby give perm ission to the m edical personnel selected by the cam p director to order X-rays, routine tests,treatm ent; to release any records necessary for insurance purposes; and to provide or arrange necessary relatedtransportation for m e/or m y child. In the event I cannot be reached in an em ergency, I hereby give perm ission tothe physician selected by the cam p director to secure and adm inister treatm ent, including hospitalization, for theperson nam ed above. This com pleted form m ay be photocopied for trips out of cam p.
Parent/Guardian Authorizations: This health history is correct and com plete as far as I know, and the person hereindescribed has perm ission to engage in all cam p activities except as noted.
__________________________________________
___________________
Parent or Guardian Signature

Source: http://d14-h.tamu.edu/files/2011/01/MedicalInfo.Youth_.pdf

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