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Medical form internet version.pub

Camp Romimu Medical Form
533 Oak Drive, Far Rockaway, New York 11691, Tel (718) 327-3000, Fax (718) 327-5144 Name _________________________________________________________ Date of Birth ______________________________ ___ Parents’ Summer Address__________________________________________ City, State, Zip________________________________ Parents’ Winter Address___________________________________________ City, State, Zip________________________________ Home Phone(s) (summer)__________________ (winter) ________________ Business Phone(s) ___________________________ Cell Phone(s) _______________________________________________________________________________________________ If not available in an emergency notify: 1)_____________________________ Phone______________________________________ 2)_____________________________ Phone_____________________________________ Medical Insurance Carrier _________________________________________ Policy Holder’s Name ___________________________ Group Name and ID# _____________________________________________ CoPay Amount ______________________________ Prescription Plan ID# _____________________________________________ CoPay Amount _________________________________ Does your insurance company require you to change your Primary Care Physician? ____ Yes ____No Does your insurance company require a referral to see a specialist (e.g., orthopedist, podiatrist)? ____ Yes ____No Parent’s Authorizations
My son is registered for: □ Whole Summer □ First Trip □ Second Trip ♦ Camp Notification: I will notify Camp Romimu if my son is exposed to any communicable disease during the three weeks prior to camp or
has had recent injury or medical issue that the camp should know about. If your son has a chronic or acute medical condition, it is imperative that the camp be notified. If your child is being treated for asthma, please send along the nebulizer and tubing, as well as all inhalers. If your child has had an anaphylactic reaction, please send along an epipen that has not expired. It is important that the nurse is notified before camp begins. To speak to the camp nurse regarding confidential medical information regarding your son, please call her during June. Her phone number will be included in the Camp Handbook which is sent out after Pesach. ♦ Medical Treatment Authorization: The health history listed on this medical form is accurate. The person herein described has permission to
engage in all prescribed camp activities except as noted by me. I hereby give permission to the physician or registered nurse selected by the camp director 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 director to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named above. ♦ Community General Hospital Authorization: I/We, the undersigned, parents of the above listed minor at Camp Romimu do hereby author-
ize Camp Romimu and/or Rabbi Shlomo Pfeiffer, and/or designee, as our agent(s) to consent to any diagnostic procedure or medical care which is deemed advisable by, and is to be rendered under the general supervision of, any licensed physician and surgeon at Community General Hos- pital, when such diagnosis or treatment is rendered at said hospital. It is understood that this authorization is given in advance of any specific need for treatment but is given to provide authority on the part of the aforesaid agent(s) to give specific consent to any and all such diagnoses, treatment or hospital care which the physician in the exercise of his best judgment may deem advisable. The authorization shall remain in effect unless revoked in writing to said agent(s). ♦ Contacting Parents: It is understood that the hospital and medical treatment authorizations will only be used in an emergency. Every attempt
will be made to contact the parents before the authorizations are used.
Meningitis Immunization:
□ My child has had the meningococcal meningitis immunization (Menomune™) within the past 10 years. Date received: _______________ [Note: The vaccine’s protection lasts fo r approximately 3 to 5 years. Revaccination may be considered □ I have read, or have had explained to me, the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that my child (I) will not obtain immunization against meningococcal meningitis disease.
Signature of Parent _____________________________________________ Date _________________________
Please attach a copy of the front and back of your medical and prescription cards. We must have both sides. Please note: If
insurance information is not provided, you may be billed at the standard physician and pharmacy rates.

Attach a Copy of the
Attach a Copy of the
Attach a Copy of Your
Front of Your
Back of Your
Prescription Drug
Medical Insurance Card
Medical Insurance Card
Insurance Card Here
Please complete both sides in full and return before May 1st
Camp Romimu Medical Form
533 Oak Drive, Far Rockaway, New York 11691, Tel (718) 327-3000, Fax (718) 327-5144 Please indicate which medications are acceptable for administration
Date of Most
to this applicant. Dosage will be given per label instructions by age
Recent Booster
and weight.
Name of Medication Accepted Accepted
Alternative Medication
Past Illness or Diseases
anaphylactic reactionasthmarheumatic fever BEHAVIOR
Important: Is applicant under any medical or dietary treatment to be continued at camp. Please list specific medications,
dosage and frequency (If dosage/frequency is different during the summer, please indicate this in writing):
Please list any activities to be restricted: _____________________________________________________________________
Chronic or recurrent illness and suggested treatment: ___________________________________________________________
To the best of my knowledge all the information stated above is accurate. It is my opinion that this camper is physically able to engage in camp activities, except as noted. Signature of Doctor ________________________________________________________ Date______________________ Physician’s Name _________________________________________________________ Telephone # ________________ Please complete both sides in full and return before May 1st
I am writing to inform you about meningococcal disease, a potentially fatal bacterial infection commonly referred to as meningitis, and a new law in New York State. On July 22, 2003, Governor Pataki signed New York State Public Health Law (NYS PHL) §2167 requiring overnight children’s camps to distribute information about meningococcal disease and vaccination to the parents or guardians of all minors who attend the camp for seven or more nights. This law became effective on August 15, 2003. Camp Romimu is required to maintain a record of the following for each minor: ♦ A response to receipt of meningococcal meningitis disease and vaccine information signed by the minor’s ♦ Information on the availability and cost of meningococcal meningitis vaccine (Menomune™); AND ⇒ A record of meningococcal meningitis immunization within the past 10 years; OR ⇒ An acknowledgement of meningococcal meningitis disease risks and refusal of meningococcal meningitis immunization signed by the minor’s parent or guardian. Meningitis is rare. However, when it strikes, its flu‑like symptoms make diagnosis difficult. If not treated early, meningitis can lead to swelling of the fluid surrounding the brain and spinal column as well as severe and permanent disabilities, such as hearing loss, brain damage, seizures, limb amputation and even death. Cases of meningitis among teens and young adults 15 to 24 years of age have more than doubled since 1991. The disease strikes about 3,000 Americans each year and claims about 300 lives. A vaccine is available that protects against four types of the bacteria that cause meningitis in the United States ¾ types A, C, Y and W‑135. These types account for nearly two thirds of meningitis cases among teens and young adults. I encourage you to carefully review the enclosed materials. Please speak to your pediatrician to recommend whether your son(s) should be vaccinated. Information about the availability and cost of the vaccine can be obtained from your health care provider and by visiting the manufacturer’s website at www.meningitisvaccine.com. You can also find information about the disease at the New York State Department of Health website: WWW.HEALTH.STATE.NY.US, and the website of the Center for Disease Control and Prevention (CDC): WWW.CDC.GOV/NCIDOD/DBMD/DISEASEINFO. Please check the appropriate response regarding meningococcal vaccination
on the medical form and return it the office before May 1st.
New York State Department of Health
Bureau of Communicable Disease Control

Meningococcal Disease
Information for Parents of Children at Residential Schools and Overnight Camps
What is meningococcal disease?
Meningococcal disease is a severe bacterial infection of the bloodstream or meninges (a thin lining covering the brain
and spinal cord).
Who gets meningococcal disease?
Anyone can get meningococcal disease, but it is more common in infants and children. For some college students, such
as freshmen living in dormitories, there is an increased risk of meningococcal disease. Between 100 and 125 cases of
meningococcal disease occur on college campuses every year in the United States; between 5 and 15 college students
die each year as result of infection. Currently, no data are available regarding whether children at overnight camps or
residential schools are at the same increased risk for disease. However, these children can be in settings similar to col-
lege freshmen living in dormitories. Other persons at increased risk include household contacts of a person known to
have had this disease, immunocompromised people, and people traveling to parts of the world where meningitis is
How is the germ meningococcus spread?
The meningococcus germ is spread by direct close contact with nose or throat discharges of an infected person. Many
people carry this particular germ in their nose and throat without any signs of illness, while others may develop serious
What are the symptoms?
High fever, headache, vomiting, stiff neck and a rash are symptoms of meningococcal disease. Among people who de-
velop meningococcal disease, 10-15% die, in spite of treatment with antibiotics. Of those who live, permanent brain
damage, hearing loss, kidney failure, loss of arms or legs, or chronic nervous system problems can occur.
How soon do the symptoms appear?
The symptoms may appear 2 to 10 days after exposure, but usually within 5 days.
What is the treatment for meningococcal disease?
Antibiotics, such as penicillin G or ceftriaxone, can be used to treat people with meningococcal disease.
Is there a vaccine to prevent meningococcal meningitis?
Yes, a safe and effective vaccine is available. The vaccine is 85% to 100% effective in preventing four kinds of bacte-
ria (serogroups A, C, Y, W-135) that cause about 70% of the disease in the United States.
Is the vaccine safe? Are there adverse side effects to the vaccine?
The vaccine is safe, with mild and infrequent side effects, such as redness and pain at the injection site lasting up to
two days.
What is the duration of protection from the vaccine?
After vaccination, immunity develops within 7 to 10 days and remains effective for approximately 3 to 5 years. As with
any vaccine, vaccination against meningitis may not protect 100% of all susceptible individuals.
How do I get more information about meningococcal disease and vaccination?
Contact your family physician or your student health service. Additional information is also available on the websites
of the New York State Department of Health, www.health.state.ny.us ; the Centers for Disease Control and Prevention
www.cdc.gov/ncid/dbmd/diseaseinfo; and the American College Health Association, www.acha.org .

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