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Milvet.state.pa.us

OMK HERO CAMP Health History Form
State Youth Coordinator, Bldg 7-3 Wiley Road Fort Indiantown Gap Annville, PA 17003 (Please complete one form per child – must be submitted 4 weeks before camper’s arrival)
EMERGENCY INFORMATION
INSURANCE INFORMATION
(Alternative persons to be called in an emergency)
CHILD RELEASE AUTHORIZATION
List everyone AUTHORIZED to pick child up,
i
l di
VACCINATIONS
(APPROX. DATE IMMUNIZED)
PAST OR PRESENT MEDICAL INFORMATION (Please check all that apply)
ADD/ADHD
Heart Defect/Disease
Head Lice
German Measles
(recent)
Recent Hospitalization
Bed-wetting
Other conditions:
Under Doctor’s Care
Sleepwalking
Seizures
Tuberculosis
Diabetes
Chicken Pox
For each box checked, please explain:
ALLERGIES (Please check all that apply)
Hay Fever
Bee Stings
Penicillin
Poison Oak/Ivy
Bee Sting Kit?
insects/animals
Current medications to be continued at camp (include dosage/frequency):
Dietary restrictions?
Any reason to restrict fully activity including swimming, long hikes, strenuous physical games?
If yes, please explain:
NON-PRESCRIPTION MEDICATIONS
I authorize the following medications to be administered as needed:
Benadryl
Neosporin
Calamine
Chloraseptic
Ibuprofen
Required Health Examination by Licensed Physician
All campers are required to have written confirmation of a health examination within 12 months of attending OMK

HERO Camp. Camp is held in an outdoor setting, with programs that are VERY active, including hiking, games, swimming,
ropes courses, zip lines, rappelling, climbing rock walls, and traditional camp activities. Your careful consideration is
I have examined the child named on this form within the past year. Date of examination:
After the examination and my review of his/her health history, it is my opinion that this person is physically able to engage in Is this applicant under the care of a physician for any conditions?
Any specific activities to be encouraged or limited by physician’s advice?

Any treatment or medications to be continued at camp (please give specific dosage information:
This health history is correct, as far as I know, and the person herein has permission to engage in all prescribed program activities. I give my permission to the physician selected by the camp to order X-rays, routine tests, and treatment for the health of my child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child named above. We recognize that the participant must follow safety instructions, remain in areas designated by staff and refrain from any behavior that is harmful to oneself or others. Failure to adhere to program policies will be cause for participant’s dismissal. This form may be photocopied for use away from the main program site. I authorize the camp staff to apply sunscreen to my child’s exposed skin, on an as-needed basis. Parent/Guardian Signature____________________________________________________Date: ______________ To be read, understood and signed by Camper and Parent.
We welcome you to our summer camp program. In order to provide the best possible camp experience for everyone, there are certain rules and policies that have been established for the health and safety of all involved. 1. The camper agrees to abide by the rules and regulations set by the camp for the health, safety and welfare of all 2. Campers are not allowed to smoke, chew tobacco, possess any smoking materials, alcohol or illegal drugs. 3. All medications/prescribed drugs must be kept in the In the Infirmary under the control of the Nurse. 4. Campers are not to possess or use firecrackers or explosives. Campers may not possess weapons of any kind. 5. Willful destruction of property will be the financial responsibility of the camper’s parent. 6. Campers may not leave camp property or established boundaries without staff permission.
7. Continued inappropriate behavior, including threatening, swearing, not following directions, teasing, sexual
harassment/intimidation and improper behavior in transportation vehicles, may result in IMMEDIATE DISMISSAL
FROM CAMP.
8. The camp and National Guard is not responsible for articles of clothing or personal belongings lost or damaged. We reserve the right and WILL send ANYONE home (at parents’ expense and liability) that violates these rules. It is the responsibility of the parent/guardian to pick up or arrange transportation home for the camper. The camp administrator reserves the right to determine what constitutes a violation of these rules and will enforce them as necessary. I have read, understood and will abide by the rules as stated above throughout my stay at camp.

Camper Signature:
Parent/Guardian Signature:

Source: http://www.milvet.state.pa.us/DMVA/Docs_PNG/familyprogram/youth/OMK_HERO_CAMP_2010/OMK_Hero_Camp_Health_History_Form_2010.pdf

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