C:\wpdocs\2013\staff forms\2013 medical examination & information form.wpd

2013 CAMP KAMAJI MEDICAL EXAMINATION AND INFORMATION FORM
Prior to May 15th, please return to CAMP KAMAJI FOR GIRLS, 7436 Byron Place, St. Louis, MO 63105
After May 15th, please return to CAMP KAMAJI FOR GIRLS, 32054 Wolf Lake Road, Cass Lake, MN 56633
This person has enrolled as a camper or staff member in a summer residential program at Camp Kamaji for Girls. Thisprogram includes physical activity (i.e., swimming, canoeing, tennis, horseback riding, climbing wall!!) and takes place in theMinnesota North Woods. Our healthcare staff will use your information to help meet the health needs of the person described.
NAME: BIRTHDATE AGE
HEIGHT: FT. IN.
WEIGHT: LB.
BP: RESTING HEART RATE:
“ This person’s immunization record is up-to-date. Yes “ No “ Please attach copy of complete Immunization Record.
Special Note: The following up-to-date vaccinations are recommended for participation in camp program: “ Given the recent outbreak of Pertussis, in addition to earlier DtaP vaccines, adolescents 11 through 18 years of age (preferably at age 11-12 years) and adults 19 and older should receive a single dose of Tdap.
“ It is recommended that adult staff members receive a tetanus and diphtheria booster (Td) every 10 years — a Tdap vaccine can be substituted for one of the Td boosters.
“ The CDC recommends the meningococcal conjugate vaccine (MCV4) for 11-18 year olds’; the first dose should be given at 11-12 years of age with a booster dose at given between age 16 and 18.
“ This person is under the care of a physician for the following reason(s): “ Describe any treatment(s) to be continued at Camp Kamaji for this person: “ This person takes medication. Yes “ No “ PLEASE LIST ALL MEDICATIONS (PRESCRIPTION AND OTC) ON OVERSIDE ALONG
WITH DOSAGE AND REASONS FOR TAKING. KKK KK
“ This person will suspend specific medication while at camp. Yes “ No “ PLEASE LIST MEDICATION ON OVERSIDE AND REASONS
FOR SUSPENSIONKKKKKKKKK
Should exposure occur, how should the allergic reaction be treated? If this is an anaphylactic response, will this person be bringing an “ Describe significant physical findings regarding this person and/or describe limitations which may impact the person’s participation in camp’s “ Mental, Emotional and Social Health: Please check any that apply and explain further on overside.
“ This person has been diagnosed with Attention Deficit Disorder (ADD) Or ADHD.
“ This person has a psychiatric diagnosis such as depression, OCD, panic/anxiety disorder.
“ This person has an emotional health concern (specify )“ During the past academic year, this person has seen or is currently seeing a professional to address mental/emotional concerns.
“ This person has had a significant life event that continues to affect her/his life at camp.
— please turn over —
CAMPER/CIT NAME:
“ Over-The-Counter Medications (OTCs): These medications, stocked in Kamaji’s Health Center, are used to manage illness or injury concerns
and are used on as needed basis. PLEASE CROSS OUT those which are CONTRAINDICATED for this person:
Other (please list)
MEDICATIONS this person usually takes but which are being SUSPENDED during the time she is at camp and REASONS FOR
SUSPENSION:
Please list all MEDICATIONS, both prescription and over-the-counter, TO BE ADMINISTERED at Kamaji (name, dosage, frequency) and reason
for taking.
Name of Medication
Reasons for Taking It
Doses Given and When
“ Breakfast Dose: “ Lunch Dose: “ Dinner Dose: “ Bedtime Dose: “ Other: “ Breakfast Dose: “ Lunch Dose: “ Dinner Dose: “ Bedtime Dose: “ Other: “ Breakfast Dose: “ Lunch Dose: “ Dinner Dose: “ Bedtime Dose: “ Other: “ Breakfast Dose: “ Lunch Dose: “ Dinner Dose: “ Bedtime Dose: “ Other: “ We may have neglected to ask something you feel is needed to adequately address the health needs of this person. In that case,
please add comments (on separate sheet) and attach. Thank you for helping provide a successful camp experience for this person.
I have examined the person herein described and have discussed the camp program with the camper’s parent(s)/ guardian(s). It is my
opinion that the camper is physically and emotionally fit to participate in an active camp program (except as noted on overside.)
Signature of Examining Physician/Nurse Practitioner:
Date of Most Recent Medical Examination:
Print or Stamp Examiner’s Name:
Address:
Phone and Pager (w/Area Code):

Source: http://kamaji.com/wp-content/uploads/2013MedicalExaminationFormStaff.pdf