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Microsoft word - seacamphealthform2013.doc
2014 OHIO 4-H SEACAMP PARTICIPANT/MEMBER HEALTH HISTORY
This form must be completed for each participant by the parents/guardians of minors. This information will be kept confidential and used only for the welfare of the participant.
Age ________ Date of Birth _______________________________________
Address __________________________________________________________________________________________________________ (Street)
Phone (home) ___________________________________________ Guardian’s Work Phone ________________________________
Parent Name _______________________________________
Physician’s Name _________________________________
Cellular Phone _________________________________ Dentist’s Name ___________________________________
Other Person ______________________________________
INSTRUCTIONS FOR MEDICATIONS
1. All prescription drugs MUST be carried in the container in which they were issued (with medical orders and physician’s name
intact), and given to the nurse/health director. Others will not be accepted.
2. If you need over-the-counter medications not listed below, they must be in the original container and must be stored under lock and
key by the nurse/health director or a responsible adult during the 4-H event.
CHECK MEDICATIONS BELOW, THAT PARTICIPANT MAY RECEIVE IF DEEMED NECESSARY:
Check this box to grant permission for your child to be administered a motion sickness medication for the prevention of
sea sickness. Sea Camp uses Meclizine HCl 25mg (a generic form of Dramamine Less-Drowsy Formula, also known as
Bonine.) We strongly encourage all campers to take this precaution. Charter boats will not turn around for passengers
who are seasick.
LIST APPROXIMATE DATE IF PARTICIPANT HAS HAD OR BEEN EXPOSED TO:
Measles _____________ Mumps _____________
Date of last menstural period __________________
Operations or serious injuries requiring medical treatment (specify): ____________________________________________________
Check below if participant is subject to:
PLEASE COMPLETE OTHER SIDE
Check if Participant is allergic to:
Foods (specify) ______________________________________________________________________________________________
Medication: Prescription or non-prescription drugs (specify) ___________________________________________________________
Serious Ivy, Oak, or Sumac Poisoning ____________________________________________________________________________
Bee or Insect Stings _________________________ Prescribed Treatment _______________________________________________
LIST ALL PRESENT MEDICAL AND ALLERGIC CONDITIONS (Contact Lenses, Braces, Diabetes, etc.) which require medication, treatment, or special restrictions or considerations in participation. Conditions: ____________________________________________________________________________________________
SPECIFY ANY RESTRICTIONS IN ACTIVITIES:
Please attach a current immunization record or write in the date (month & year) of basic immunizations and most recent booster doses.
Measles (hard measles, red measles, Rubeola)
PARENT/GUARDIAN MEDICAL RELEASE
__________________________________ has my permission to participate in the Ohio 4-H program and activities (with the exception of those restricted activities listed). I understand participants will be supervised. I understand the 4-H staff and volunteers; Ohio State University Extension and The Ohio State University are not responsible in the event of accidental injury or illness, nor for the compounded injury or illness to the participant’s present medical conditions listed. I further understand in case of serious injury or illness I will be notified. If I cannot be contacted, I give my permission to the attending physician to hospitalize, secure proper treatment, and to order injection, anesthesia, or surgery for the participant as named above. Signature _____________________________________________Date ______________________________________
OSU Extension embraces human diversity and is committed to ensuring that all educational programs conducted by Ohio State University Extension are available to clientele
on a nondiscriminatory basis without regard to race, color, age, gender identity or expression, disability, religion, sexual orientation, national origin, or veteran status.
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