AFAA CAMP 2018 REGISTRATION CHECKLIST

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1 AFAA CAMP 2018 REGISTRATION CHECKLIST All youth and all parent-campers must submit the following forms: Camp Registration Drop Off/Pick Up Emergency Information Medical Insurance Information (photocopy of card) Anaphylaxis Plan (if applicable) signed by physician Asthma Plan (if applicable) signed by physician Physical signed physician (it can be your clinic s standard form) Medical History Emergency Medication Boys and Girls Club form (for statistical purposes) Facial photo (either on Anaphylaxis Plan or separately submitted) NOTE: If ALL forms above are submitted together, camper will receive $20 discount from camp fees. PAYMENT Payments are by check only. Checks should be made out to AFAA or Anaphylaxis & Food Allergy Association of MN. DONATIONS AFAA - a volunteer-run non-profit - is grateful for donations to AFAA Camp and its other food allergy education, advocacy, and support programs. Donations can be made by check to AFAA or by credit card online at minnesotafoodallergy.org. Your donations help keep costs reasonable and can help provide need-based camp scholarships. In-kind donations for AFAA Camp can be arranged by contacting AFAA at camp@minnesotafoodallergy.org. In-kind donations for other AFAA programs and events are welcome also. For more information, contact AFAA at (651) Thank you! 0

2 AFAA CAMP 2018 REGISTRATION FORM (This form must be completed for all campers, including infants and parents participating in family camp and/or day camp.) General information: Name Date of birth Age Grade completed Male Female Address City State Zip Country Parent s/guardian s Home Phone Numbers Parent s/guardian s Cell Phone Numbers Parent s/guardian s Work Phone Numbers Religious preference, if any Has your child ever been away from home? Yes No Has your child been to camp before? Yes No Does your child have any fears of bugs water night animals other children adults? You may list others here or may provide details: I am registering for: Overnight Cabin Camping Youth or Adult Day Camping Youth or Adult $200 per person $150 per person I would like to be a Camper-Volunteer in a cabin I would like to be a Camper-Volunteer in a program/activity Teens: I would like to volunteer as a an assistant to a Program/Activity or to a Cabin Note: discounts will be applied after all paperwork is received and/or volunteer application accepted. List other family members attending AFAA Camp with you. Each family member must have completed registration forms to participate in camp! Enclosed is a check for (list amount): for (list number of campers) We regret that the Anaphylaxis and Food Allergy Association of Minnesota does not have the funds to offer camperships (scholarships) this year. Please help us with fundraising so we may do so next season. Behavior Agreement. I agree/my child agrees to abide by AFAA Camp and Voyageur Camp/Boys & Clubs of the Twin Cities expectations for appropriate behavior, conduct, rules, regulations, policies as stated in Camper Behavior, and that inappropriate behavior may result in being sent home from camp at my expense. Photo Waiver. I grant the Anaphylaxis and Food Allergy Association of Minnesota (AFAA) full permission to use any photographs of AFAA Camp that contain my likeness for promotional purposes. Cabin Waiver. I understand that my child will be in a cabin shared with other campers of the same sex, and possibly with family campers located on a different level of the building (i.e. loft). Cabins have closed dressing areas, closed individual shower, & closed individual toilet room. Two unrelated adults are assigned to supervise the campers in the cabin, and camp policy prohibits leaving any camper unattended. Signature of Camper Signature of Parent/Guardian 1

3 AFAA CAMP DROP-OFF/PICK-UP FORM Please indicate the adult(s) planning to transport child(ren). No child is allowed to leave with unauthorized adult! Authorized adults must have valid photo identification for picking up child(ren)! Name Relationship to child camper Name Relationship to child camper Name Relationship to child camper Please indicate drop-off and pick-up dates and times for your child according to their registration for full camp or day camp (please speak to AFAA Camp directors in advance to request exceptions to these times). Overnight Campers - camper will be dropped off at camp: Friday, June 1 st between: 5:30-6:30 p.m. (camper will eat supper at home) Overnight Campers - Camper will be picked up at camp: Sunday, June 3 rd at: 12 p.m. (families are invited to closing program at this time) Day Campers - camper will be dropped off at camp: Friday, June 1 st between: 5:30-6:30 p.m. (camper will eat supper at home) Saturday, June 2 nd at: 9 a.m. (camper will eat breakfast at home) Sunday, June 3 rd at: 9 a.m. (camper will eat breakfast at home) Day Campers - Camper will be picked up at camp: Friday, June 1 st at: 8 p.m.* Saturday, June 2 nd at: 8 p.m.* Sunday, June 3 rd at: 12 p.m. (families are invited to closing program at this time) *please make arrangements with AFAA Camp if you would like to pick up your child earlier 2

4 AFAA CAMP EMERGENCY INFORMATION FORM ATTACH PHOTOCOPY OF BOTH SIDES OF INSURANCE CARD. (If family has no medical insurance, state none. ) ATTACH ANAPHYLAXIS ACTION PLAN SIGNED BY PHYSICIAN ATTACH ASTHMA ACTION PLAN SIGNED BY PHYSICIAN ATTACH PHYSICAL EXAM SIGNED BY PHYSICIAN from the last 12 months (use your clinic s standard form) Health/accident insurance company Policy Number and Group Number Emergency Contact #1: Name Relationship Address Phone Numbers (with area codes). Home Cell Work Emergency Contact #2: Name Relationship Address Phone Numbers (with area codes). Home Cell Work Informed Consent and Hold Harmless/Release Agreement I give consent for myself and/or my child to participate in AFAA Camp and its activities. I understand that participation requires participants to abide by applicable rules and standards of conduct. I release the Anaphylaxis and Food Allergy Association of Minnesota (AFAA), the Boys and Girls Clubs of the Twin Cities, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with AFAA Camp from any and all claims or liability arising out of this participation. I approve the sharing of the information on medical and registration forms with AFAA Camp volunteers and professionals who need to know of medical situations that might require special consideration for the safe conducting of activities. I agree that camp staff will make decisions regarding the well-being of me or my child in accordance with safety standards, applicable laws and ordinances, & camp protocols. I give permission to the camp to provide, seek, and consent to health care, administration of prescribed or authorized medications, necessary emergency transportation and medical records for me/my child. In case of an emergency involving me or my child, I understand that every effort will be made to contact the individual listed as the emergency contact person. In the event that this person cannot be reached, permission is hereby given to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, injections of medication for me or my child (medical providers are authorized to disclose to the adult leader in charge examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with me.) I agree that all emergency expenses will be paid by me and my insurance company, including medical, travel, legal, & phone calls. Signature of Parent/Guardian 3

5 AFAA CAMP MEDICAL HISTORY FORM Indicate whether you have/you child has the following (specifically list what needs to be avoided): Food allergies, eosinophilic or metabolic or other conditions restricting diet: **Circle foods above that may cause you/your child to have anaphylactic reactions** Are you/your child sensitive to tactile exposure? Yes Are you/ your child sensitive to airborne exposure? Yes Does your child know to avoid the above listed foods? Yes No Not Applicable Environmental allergies (e.g. insects, pollen, dust mites, mold, etc.) Celiac disease Vegan diet (no animal products) Vegetarian diet (please circle whether eggs or milk ingredients are avoided) Kosher diet Halal diet Check if you have/your child has any of these other conditions: Allergies to Medications (list below) Learning disorders (e.g. ADHD, ADD, Asthma auditory processing) Bleeding disorders Menstrual problems Back problems Muscular/skeletal condition COPD Psychiatric/psychological or Diabetes emotional difficulties Ear/sinus problems Seizures Eye correction (glasses, contacts) Sickle cell disease Fainting spells Skin conditions (e.g. eczema, acne) GI problems (e.g. irritable bowl, Sleep disorders (e.g. sleep apnea, constipation) night terrors, walking) Headaches Social challenges (e.g. shyness, Heart disease (e.g. CHF, CAD, MI) impulsiveness, autism) HIV Stroke/TIA Hypertension (high blood pressure) Surgery or serious injury Joint or muscular problems Thyroid disease Kidney disease or bed wetting Other(s) not listed above: No No 4

6 Please describe condition(s). Attach additional pages if needed: Please list all medications and vitamins prescribed & over-the-counter currently taken by you/your child: 1. Medication Dosage Frequency/time(s) of day to take medication 2. Medication Dosage Frequency/time(s) of day to take medication 3. Medication Dosage Frequency/time(s) of day to take medication 4. Medication Dosage Frequency/time(s) of day to take medication 5. Medication Dosage Frequency/time(s) of day to take medication All medication must be in original packaging/bottle! Other than vitamins, please refrain from bringing/sending any supplements to camp. Which of the following may be given to your child by camp staff: Tylenol ibuprofen Benadryl calamine lotion sunscreen insect repellent Indicate the year for each vaccination/disease you/your child had (circle if disease rather than vaccination). STARS * INDICATE REQUIRED IMMUNIZATIONS (exemptions allowed only for medical reasons, and must confirmed by signed letter from board-certified physician). Note: Tetanus immunization must have been received within the last 10 years. *Tetanus *Pertussis *Diphtheria *Measles *Mumps *Rubella *Polio Chicken pox Hepatitis A Hepatitis B Influenza Menactra Other (i.e., HIB) My child is: independent with urinary and bowel needs requires adult assistance with urinary and bowel needs will be provided with change of clothing in case of wetting or soiling accidents needs Pull-Ups at nighttime needs to be awakened during the night to use toilet 5

7 AFAA CAMP EMERGENCY MEDICATION FORM I/my child has the following epinephrine autoinjector(s): EpiPen Auvi-Q Adrenaclick Indicate number of autoinjectors with you/your child I/my child has an asthma inhaler Yes No Camper Agreement: I agree to: Carry my epinephrine autoinjector(s) with me rather than with camp staff Keep my epinephrine autoinjector(s) at room temperature Use epinephrine autoinjector(s) on myself only in an emergency Notify camp staff immediately if I feel the need to use epinephrine autoinjector(s) My epinephrine autoinjector(s) are carried in my (please circle): backpack waistpack medicine bag pocket other Signature of camper (Note: underage campers must have parent/guardian signature below) I agree to: Carry my asthma inhaler with me rather than with camp staff Keep my asthma inhaler at room temperature Use asthma inhaler on myself only in an emergency Notify camp staff immediately if I feel the need to use asthma inhaler My asthma inhaler is carried in my (please circle): backpack waistpack medicine bag pocket other Signature of camper (Note: underage campers must have parent/guardian signature below) For parents of underage children, check appropriate boxes and sign below: My child is authorized to carry his/her epinephrine My child is NOT authorized to carry his/her epinephrine camp staff or parent/cabin leaders are asked to carry it My child is NOT authorized to carry his/her epinephrine pleased store in the camp/medical office My child is authorized to carry his/her asthma inhaler My child is NOT authorized to carry his/her asthma inhaler camp staff or parent/cabin leaders are asked to carry it My child is NOT authorized to carry his/her asthma inhaler please store in the camp/medical office I agree that my child carries epinephrine appropriately, and that the medication is current I will provide a back-up autoinjector for the camp/medical office I agree that my child carries asthma inhaler appropriately, and that the medication is current Signature of Parent/Guardian 6

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ASTHMA ACTION PLAN Name: DOB: Asthma Severity Allergies: Other Triggers: Avoid asthma trigger(s) Intermittent Dust mites Animals Viral Weather No smoking in home or car Mild persistent Mold Pollen

11 ASTHMA ACTION PLAN Name: DOB: Asthma Severity Allergies: Other Triggers: Avoid asthma trigger(s) Intermittent Dust mites Animals Viral Weather No smoking in home or car Mild persistent Mold Pollen Exercise Smoke Inhaler technique reviewed Moderate persistent Other: Other: Flu shot in Fall Severe persistent Food allergies: Medication allergies: Green Zone: I feel good Take CONTROLLER MEDICINE every day to control your asthma this may include allergy medicine. ¾Can work and play Medication Dose How Often ¾Can sleep at night Asmanex (mometasone) 110 mcg 220 mcg puff(s) time(s) per day ¾No cough or wheeze Flovent (fluticasone) 44 mcg 110 mcg 220 mcg puff(s) time(s) per day Pulmicort Respules (budesonide) 0.25 mg 0.5 mg 1 mg time(s) per day Peak Flow to Pulmicort Flexhaler (budesonide) 90 mcg 180 mcg puff(s) time(s) per day (80%-100% of Personal Best) QVAR (beclomethasone) 40 mcg 80 mcg puff(s) time(s) per day Advair Diskus (fluticasone/salmeterol) 100/50 250/50 500/50 1 puff twice daily Advair HFA (fluticasone/salmeterol) 45/21 115/21 230/21 2 puffs 2 times per day Symbicort (budesonide/formoterol) 80/ /4.5 2 puffs 2 times per day Singulair (montelukast) 4 mg 5 mg 10 mg daily Albuterol Xopenex (levalbuterol) 2 puffs minutes before exercise and prior to exposure to triggers. Additional orders: Yellow Zone: Keep taking Green Zone CONTROLLER MEDICINES. Take the following RELIEVER MEDICINES to keep asthma I do not feel good from getting worse. ¾At first sign of cold with Medication Dose How often cough Albuterol Nebulizer 2.5 mg in 3 ml NS (premixed vial) Every 4 hours ¾Wake up at night with cough Albuterol Inhaler 2 puffs Every 4 hours ¾Wheeze, tight chest, or Xopenex Nebulizer 0.31 mg 0.63 mg 1.25 mg Every 4 hours trouble breathing Xopenex Inhaler 2 puffs Every 4 hours Peak Flow to (50%-79% of Personal Best) Additional orders: Call or be seen if symptoms/peak flow are not improving after first 48 hours in the yellow zone, or if reliever medicine does not last 4 hours. Red Zone: I feel awful Take these medicines NOW and call your health care provider. KEEP TAKING the GREEN and YELLOW ZONE MEDICINES. ¾Getting worse and meds Medication Dose How often not helping Prednisone mg tablet(s) time(s) daily for 5 days ¾Breathing is hard and fast Prednisolone Syrup 5 mg/5ml 15 mg/5ml ml times(s) daily for 5 days ¾Coughs continuously Orapred disintegrating tablet(s) 10 mg 15 mg 30 mg tablet(s) time(s) daily for 5 days Increase above noted dose Albuterol Xopenex to every hour(s) Peak Flow less than Additional orders: (less than 50% of Personal Best) If breathing does not improve and you cannot immediately contact your health care provider, go to the emergency room. Call 911 if: you can t talk in full sentences fingernails or lips are grey or blue you can t get air you are worried about getting through the next 30 minutes Return to Clinic in: days weeks months year This form provides consent for school/day care to administer to my child the above medicine(s) as provided by parent or guardian and allows the child to carry the inhaler for which the provider has assessed ability and if approved by the school nurse. Parent/Guardian signature Date Health Care Provider signature Date Clinic phone number An affiliate of Children s Hospitals and Clinics of Minnesota 10

Peninsula Puffers Asthma Camp 2019 Application

Peninsula Puffers Asthma Camp 2019 Application Camp is for children, ages 8 to 14, who take medications daily for their asthma. Online Registration is available at www.aafaalaska.com CAMP DATES: June 9-