Camp Health History Form

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Page 1

Dear Parents, Guardians, and Staff: Welcome to the Cazadero Camp Health History Form. The information collected here is used to help us keep everyone safe and healthy while in our care. All information is confidential; only shared on a need-to-know basis.

This form will ask for some information that you might want to have ready before you begin:
image files of your camper's medical insurance card, front and back.
immunization records: these can be entered by hand or uploaded as an image file.
You can stop and save your work, and come back later to add information. Look for the links at the top and bottom of the page and follow the instructions.

Note: This is our standard pre-COVID Health History Form. COVID specific safety issues will be addressed in a separate form.

IDs

Contact ID

Account ID

Registration ID

Are you filling this form out for a Cazadero camper or a Cazadero staff member?

CamperStaff or Volunteer under 18 years oldAdult Staff Member, Conductor o Volunteer (at least 18 years old)

Page 2

Participant Information

Session Attending

First Name

Last Name

Date of Birth

Gender Identity

MaleFemaleOther

If other, please explain

Primary Contact Email

Home Street Address

City

State

Postal Code

Emergency Contacts to be contacted in case of illness or injury:

Primary Contact: Parent/guardian with legal custody

First Name

Last Name

Relation to Camper

Primary Contact Phone

Other Contact Phone

Relationship to camper:

Second Parent/guardian or other emergency contact

First Name

Last Name

Relation to Camper

Primary Contact Phone

Other Contact Phone

Relationship to camper:

Additional contact in the event parent/guardians cannot be reached

First Name

Last Name

Relation to Camper

Primary Contact Phone

Other Contact Phone

Relationship to camper:

Emergency Contacts to be contacted in case of illness or injury:

Primary Emergency Contact:

First Name

Last Name

Relationship to participant:

Primary Contact Phone

Other Contact Phone

Second Emergency Contact:

First Name

Last Name

Relationship to Participant:

Primary Contact Phone

Other Contact Phone

Additional contact:

First Name

Last Name

Relationship to participant:

Primary Contact Phone

Other Contact Phone

Allergies: Medications or the Environment

Please let us know if the participant is allergic to any medications or the environment; food recorded in a separate section below.

No known allergies.Yes, has the following allergies.

MedicationsEnvironmental/other

Please list the allergies and describe the reactions.

Activity Restrictions

I have reviewed the camp program and activities and the participant can participate with

no restrictions.the restrictions and adaptations described below.

Please describe any participation limitations.

Medical Insurance Information and Consent to Treat Authorization

Does the participant currently reside in the United States.

YesNo

International Insurance

If they live outside of the US, will insurance be provided for the participant while they are at camp?

YesNo

Please describe the type of insurance that will be provided.

Please use this field to upload insurance documents including an insurance card front and back if there is one.

This participant is covered by family medical/hospital insurance.

YesNo

Health Insurance and Policy Information

Carrier

Policy #

Group #

Medical Insurance ID Card

To complete this section please upload a copy of the participant's insurance card, front and back. This ensures that we can quickly access all the information we will need in the event of an emergency.

Front of card.

Please send JPEG or PDF files.

Back of card.

Consent to Treat

Parent/Guardian (or Participant if over 18) Authorization for Health Care

This health history is correct and accurately reflects the health status of the participant to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the medical personnel selected by the camp to order routine tests, x-rays, treatment, and necessary transportation of the above named person for both routine heath care and in the event of a medical emergency. If I cannot be reached in an emergency, I give my permission to the medical personnel to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this participant. I understand that the information on this form will be shared on a "need to know" basis with camp staff. In addition, the camp has permission to obtain a copy of my child's health record from providers who treat my child and these providers may talk with the program's staff about my child's health status.

Consent to Treat/Uninsured

Parent/Guardian (or Participant if over 18) Authorization for Health Care/ Declared Non-insured

In the event that I do not have any or sufficient medical insurance coverage for the treatment of my child, I will be responsible for the full payment of any and all medical expenses incurred during the treatment of my child.

Authorization for Health Care

I understand that typing my name below constitutes a legal signature indicating agreement to the above Authorization for Health Care.

Electronic Signature of Parent/Guardian or Participant

Please type your first and last name

Todays Date

Health Care Providers

Primary Physician or Clinic

Physician Phone

Dentist's Name (Optional)

Dentist's Phone

Additional Health Care Providers (Optional)

Type

Name

Phone

Immunization History

The participant has been immunized.

YesNo

Boosters


COVID booster (most recent)
Tetanus booster (most recent)
Tuberculosis TB Test		NegativePositive

Please describe your TB status.

Immunization History

The participant has been fully immunized.

YesNo

If the participant has not been fully immunized, please sign the following statement.

I understand and accept the risks to my child from not being fully immunized.

I understand that checking this box constitutes a legal signature indicating agreement to the above statement of risk.

Electronic Signature of Parent/Guardian or Participant (if over 18)

Please type your first and last name

Todays Date

Please provide your child's immunization history

by completing this form.by uploading a copy of their immunization records.by having your doctor's office send a copy of their immunizations.

Please let us know approximately when and how your doctor will send the immunization records to the Berkeley office. Our fax number is 510-527-2790.

Immunization Dates

	Dose 1	Dose 2
COVID-19 primary and boosters
Diptheria, tetanus, pertussis (DTaP or TdaP)
Tetanus booster (most recent)
Mumps, measles, rubella (MMR)
MMR Booster?
Polio (IPV)
Haemophilus influenzae type B (HIB)
Pneumococcal (PCV)
Hepatitis B
Hepatitis A
Varicella (Chicken Pox)
Had Chicken Pox? Let us know when.	YesNo
Meningococcal meningitis (MCV4)
Tuberculosis: if tested, date and results.		NegativePositive

Please describe your camper's TB status.

Please upload a copy of your camper's immunization record. Use the "add another response" link for any extra pages.

Medications

"Medication" is any substance a person takes regularly to maintain and/or improve their health. This includes vitamins & natural remedies, over-the-counter medications, and prescriptions.

This participant will not take any medications while attending camp.This participant will take the following daily medication(s) while at camp.

Medications while at camp

Please read these instructions before sending any medications with your camper.
You must follow these packaging instructions or we will be forced to discard the medications as unsafe and contact you for replacements.

All medications, whether prescription or over the counter, must arrive in their original packaging.
Prescriptions should have the pharmacy label showing the camper's name, dosage, and how the medication should be given.
Check the expiration date; no expired medications can be administered at camp.
Provide enough of each medication to last the duration of the camper's time at camp.

Please list every medication the participant will take while at camp.

I will upload a printout with all medications and doses described.I will use the text box below.

List medications in the box below. Please include the name, reason prescribed, and time of day to be given.

On-Site Health Center

Some common, non-prescription medications and ointments are stocked in the camp Health Center to be used on an as needed basis to manage illness and injury. Please list any over the counter medications that should not be given to your camper.

General Health History

Please check "yes" or "no" for each statement and explain "yes" answers below.

Has or does this participant...

	Yes	No
1. Ever been hospitalized:
2. Ever had surgery?
3. Have recurrent/chronic Illnesses?
4. Had a recent infectious disease?
5. Had a recent injury?
6. Had asthma/wheezing/shortness of breath?
7. Have diabetes?
8. Had seizures?
9. Had headaches?
10. Wear glasses, contacts, or protective eyewear?
11. Had fainting or dizziness?
12. Passed out/had chest pain during exercise?
13. Had mononucleosis (mono) during the past 12 months?
14. Have problems with falling asleep or sleepwalking?
15. Ever had back or joint problems?
16. Have a history of bedwetting?
17. Have problems with diarrhea or constipation?
18. Have any skin problems?
19. Traveled outside the country in the past 9 months?
20. If female, have problems with periods/menstruation?

Please explain any "yes" answers by first noting the number of the question. Please describe any orthopedic devices (ie crutches or braces) that will be brought to camp. For travel outside the country please name the countries visited and the dates of travel.

Mental, Emotional, and Social Health

We want to take the best possible care of your camper; please check "yes" or "no" for each statement.
Has your camper:

	Yes	No
1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?
2. Ever been treated for emotional or behavioral difficulties or an eating disorder?
3. During the past 12 months, seen a professional to address mental or emotional health concerns?
4. Had a significant life event that continues to affect the camper's life? (History of abuse, death of a loved one, family change, new sibling, survived a disaster, adoption, or others)

Please explain any "yes" answers by first noting the number of the question. The camp may contact you for additional information.

Is there anything else you would like us to know?

Please provide any additional information about the participant that you think important or that you think may affect your camper's ability to fully participate in the camp program.

You can use this field to upload any additional documents such as the Fit-to-Participate form signature page if you have it ready. Otherwise, email a copy of the doctor's page to: emily@cazadero.org.

Save a copy of your responses for your records.

After hitting "submit" you will be asked to confirm your submission a second time; this step allows you to make a printout or PDF file copy of your responses. You cannot come back to the form after you hit submit that second time and your doctor's office will need to see your responses before signing a "fit to participate" form.

Thank you!

Contact information for Cazadero

Cazadero Performing Arts Camp • P.O. Box 7908 • Berkeley • CA • 94707

Phone 510.527.7500, email emily@cazadero.org, or visit www.cazadero.org

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