St. Vartan Camp Diocese of the Armenian Church of America (Eastern) Department of Youth and Young Adult Ministries

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St. Vartan Camp Diocese of the Armenian Church of America (Eastern) Department of Youth and Young Adult Ministries A HEALTH HISTORY AND EXAMINATION PACKET FOR ALL ST.

1 St. Vartan Camp Diocese of the Armenian Church of America (Eastern) Department of Youth and Young Adult Ministries A HEALTH HISTORY AND EXAMINATION PACKET FOR ALL ST. VARTAN CAMP PARTICIPANTS The following information must be thoroughly filled in by the parent/guardians of minors or by an adult staff member. Health exams must be completed by approved licensed medical personnel at least every two years; however, an updated form is required annually. This information provides camp health care personnel the background to provide appropriate care based on the individual s needs. Keep a copy of the completed form for your records. Any changes to this form should be provided to camp health personnel upon the participant s arrival in camp. Forms C and D must be completed by a medical professional, with a signature at the bottom of D verifying their completion. You may attach an immunization form from your doctor s office, but it must be affixed with an equivalent signed Medical Provider s form! These forms will need to be uploaded to your ACTIVE online family portal. Please make sure your scans are bright and legible. Should you have any questions or need further assistance, please contact Kathryn Ashbahian at (212) ext. 143 or KathrynA@armeniandiocese.org. Name of Participant: Circle Session Attending: A1 A2 B1 B2 C1 C2 Insurance Information: Is the participant covered by family medical/hospital insurance? Yes No If so, indicate carrier or plan name Group # Parent s Name and Date of Birth who carries the plan: DOB: / /19 You MUST attach a photocopy of FRONT of health insurance card here. You MUST attach a photocopy of BACK of health insurance card here.

2 B Health History and Examination Form For All St. Vartan Camp Participants Name: ALLERGIES: List all known allergies (medical, food, or other), as well as the reaction and management of the allergy. Has/Does the participant: Yes No Yes No 1. Have any recent injury, illness or infectious disease?. 16. Ever had back problems? Have chronic or recurring illness/condition? Ever had problems with joints (e.g. knees, ankles)?.. 3. Ever been hospitalized? Have an orthodontic appliance?. 4. Ever had surgery? 19. Have any skin problems (e.g. itching, rash, acne)? Have frequent headaches? Have diabetes? Ever had a head injury? Have asthma?. 7. Ever been knocked unconscious? 22. Had mononucleosis in the past 12 months?.. 8. Wear glasses, contacts, or protective eye wear? Have problems with diarrhea/constipation?.. 9. Ever had frequent ear infections? 24. Have problems sleep walking? Ever passed out during or after exercise? If female: Have abnormal menstrual history? Ever been dizzy during or after exercise?.. Age of first menses: 12. Ever have seizures? 26. Have a history of bed-wetting?. 13. Ever had chest pain during or after exercise? 27. Ever had an eating disorder?. 14. Ever had high blood pressure? Ever had emotional difficulties for which 15. Ever been diagnosed with a heart murmur?.. professional help was sought?... Please explain any yes answers from the above general questions, noting the number of the questions. Please provide honest information about the participant s behavior and physical, emotional, or mental health of which the camp should be aware so we can meet their individual needs.

3 C Health History and Examination Form For All St. Vartan Camp Participants: to be completed by a Licensed Medical Personnel Name: was examined on / / Height Weight BP Which of the following Has the participant had? Measles Chicken Pox German measles Mumps Hepatitis A Hepatitis B Hepatitis C TB Mantoux Test Date of last test Result: Positive Negative Please give all dates of immunization for: Vaccine: Dates: Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr DTP TD (tetanus/diphtheria) Tetanus Polio MMR or Measles or Mumps or Rubella Haemophilus influenza B Hepatitis B Varicella (chicken pox) Recommendations and Restrictions at Camp 1. In my opinion, the above applicant is is not able to participate in an active camp program. 2. Describe all conditions for which the applicant may be under the care of a physician. Please note any limitations and/or restrictions while at camp. All medications and treatments prescribed should be listed on form D: 3. Please list any medically-prescribed meal plan or dietary restrictions: Name of family dentist/orthodontist: Phone: Address:

4 ST. VARTAN CAMP AUTHORIZATION FOR THE ADMINISTRATION OF MEDICATIONS INDIVIDUALIZED STANDING ORDERS D NAME: In order to administer medications at St. Vartan Camp, New York State Regulations require an authorized prescriber s (MD, PA, APRN) written order and parent or guardian s authorization for the nurse or camp personnel with current Medication Administration Training to administer medications. Medications must be in the original pharmacy prepared containers and labeled with the name of the child, name of the drug, strength, dosage, frequency, authorized prescriber s name and date of the original prescription. Any modifications to the prescription bottle instruction must have a doctor s note. Medication will be destroyed if it is NOT picked up on the last day of camp. Prescription Medications and Treatments Please complete with current regimen for both scheduled and as-needed medications and additional orders deemed necessary by healthcare provider to be implemented by an RN (i.e. blood draws/lab work, dressing changes, cast care, special dietary instructions). Medication Dose, route, and frequency Indication, other comment(s) Standard Over the Counter Medications, First Aid and Preventative Treatment The brand or generic equivalent medication listed below is available at camp, so please DO NOT bring the below medications to camp. Over the counter medication and treatment will be administered at the RN s discretion, ONLY if approval is indicated by the participant s medical provider with a distinct Check Mark. Acetaminophen (eg, Tylenol) Ibuprofen, (eg, Advil/Motrin) Naproxen (eg, Aleve) PMS/Menstrual Relief (eg, Midol/ Pamprin) Cough Medication (eg, Robitussin, Nyquil, Dayquil, Delsym) Gold Bond, Talc Powder Dietary Fiber (eg, Metamucil, Benefiber) Decongestant (eg, Dimetapp, Sudafed) Antihistamine (eg, Benadryl, Claritin) Throat Spray (eg, Chloraseptic) Throat Lozenge, Cough Drops Canker Sore Relief (eg, Orajel) Antacid (eg, Tums, Mylanta, Maalox) Anti-diarrheal (eg, Imodium, Pepto Bismol) Laxative (eg, Milk of Magnesia, Dulcolax, Glycerin Suppository) Antiseptic Cleanser (eg, Bactine, H ) Antibiotic Ointment (eg, Neosporin or Bacitracin) Steroidal Ointment (eg, Hydrocortisone ) Topical Antihistamine (eg, Benadryl, Caladryl) Sun care, (eg, Sunscreen, Aloe Vera, Solarcaine) Bug Repellent Eye Drops/Lubricant (eg, Visine) Swimmer s Ear Drops (eg, Auro- Dri, Swim Ear) Athletes Foot Care (eg, Tinactin) I HAVE READ THE ABOVE STATEMENTS AND AGREE TO THEIR TERMS. Parent/Guardian/Staff Signature: Date: I, the below, have completed and verified the medical information on forms B and C. Signature of Licensed Medical Personnel Printed Date Address Phone Fax

5 Permission and Consent Form I hereby give permission and consent for my child to travel off-site from the facilities of St. Vartan Camp for transportation to/from the airport or train/bus station. In addition, I give permission for my child to travel off-site from the facilities of St. Vartan Camp for medical treatment. I understand that transportation will be provided by either the St. Vartan Camp vehicle, or by automobiles owned/operated by St. Vartan Camp adult staff personnel. St. Vartan Camp will not allow or give its permission or consent for a child to travel in a vehicle driven or operated by anyone under eighteen years of age for any reason. St. Vartan Camp will not approve or give its permission or consent for a child to leave the campsite in any vehicle driven or operated for any purpose other than what is stated above. I understand that participants are not allowed to travel with any adult, other than the child s own parent or guardian, or approved St. Vartan Camp staff, unless written consent by the child s parent or guardian is provided to the camp administration. I further agree to indemnify and hold harmless St. Vartan Camp and its directors, counselors and other staff, as well as the Diocese of the Armenian Church of America (Eastern) from any and all claims and legal actions for any personal injury to my child or loss of property to me and for any injury to other persons or damage to other property which results from my child s participation in this program. Permission To Treat Waiver I hereby give permission to the camp to provide, seek, and consent to routine health care, administration of prescribed medications, and emergency treatments for me/my child, as may be necessary, including but not limited to x-rays, routine tests and treatment, and/or hospitalization. I also give permission for the camp to arrange related transportation. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. It is my intention that the camp be treated as acting in loco parentis if the person herein named is a minor. Further, it is my intention that the appropriate representatives of the camp be treated as personal representatives for the purposes of disclosing protected health information pursuant to the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of I hereby agree to fully disclose information to the camp representatives of the protected health information of the person herein described, as necessary: (i) to provide relevant information to camp representatives related to the person s ability to participate in camp activities; and (ii) in the case of minors, to provide relevant information to the camp representatives to keep me informed of my child s health status. Camper Medical Waiver I hereby acknowledge that I have primary medical responsibility for my child. I further acknowledge that I have responsibility for any expenses incurred as the result of illness or injury to my child or myself (if over 18) while a participant at St. Vartan Camp. Camper Medical Agreement I understand and agree to abide by any restrictions placed on my participation in camp activities. E I HAVE READ THE ABOVE STATEMENTS AND AGREE TO THEIR TERMS. Camper/CIT/Staff PRINT: Camper/CIT/Staff SIGNATURE: Parent/Guardian SIGNATURE (when applicable): Date: Diocese of the Armenian Church (Eastern) Department of Youth and Young Adult Ministries St. Vartan Camp Jennifer Morris, Director, Youth and Young Adult Ministries JenniferM@armeniandiocese.org (248) Kathryn Ashbahian, Associate, Youth and Young Adult Ministries KathrynA@armeniandiocese.org (212) Ext

6 St. Vartan Camp Diocese of the Armenian Church (Eastern) Department of Youth and Young Adult Ministries F Dear Parent/Guardian/Staff Member: We are 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, the New York State Public Health Law (NYS PHL) was amended to include requiring overnight children s camps to distribute information about meningococcal disease and vaccination to the parents and guardians of all campers who attend camp for seven or more nights. This law became effective on August 15, St. Vartan Camp is required to maintain a record of the following for each camper/staff member: A response to receipt of meningococcal meningitis disease and vaccine information signed by the staff member or camper s guardian ; AND Information on the availability and cost of meningococcal meningitis vaccine (Menomume TM ); AND EITHER 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 staff member or camper 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 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 types A,C,Y and W-135. These types of bacteria account for nearly two thirds of meningitis cases among teens and young adults. 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 Please note that St. Vartan Camp does not offer meningococcal immunization services. To learn more about meningitis and the vaccine, please refer to the enclosed information sheet produced by the New York State Department of Health Bureau of Communicable Disease Control, and/or consult your child s physician. You can also find information about the disease at the New York State Department of Health website the American College Health Association, and the website of the Center for Disease Control and Prevention (CDC) disseaseinfo. Thank you for your attention to this matter. Please feel free to contact our office with any further questions. Jennifer Morris Director, Youth and Young Adult Ministries Meningococcal Meningitis Vaccination Response Form New York State Public Health Law requires the operator of an overnight children s camp to maintain a completed response form for every camper who attends camp for seven (7) or more nights. Please check one box and sign below: Participant s Name: Date of Birth: / / My child has had the meningococcal meningitis immunization (Menomume TM ) within the past 10 years. [Note: The vaccine s protection lasts for approximately 3 to 5 years. Revaccination may be considered within 3-5 years.] I have read, or have had explained to me, the information enclosed regarding meningococcal meningitis disease. I understand the risks of not having the vaccine. I have decided that my child will NOT obtain immunization against meningococcal meningitis disease. Date received: Parent/Guardian/Staff SIGNATURE: Date: Diocese of the Armenian Church (Eastern) Department of Youth and Young Adult Ministries St. Vartan Camp Jennifer Morris, Director, Youth and Young Adult Ministries JenniferM@armeniandiocese.org (248) Kathryn Ashbahian, Associate, Youth and Young Adult Ministries KathrynA@armeniandiocese.org (212) Ext

7 NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Communicable Disease Control F2 Meningococcal Disease Information for College Students and 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 college 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 prevalent. 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 symptoms. What are the symptoms? High fever, headache, vomiting, stiff neck and a rash are symptoms of meningococcal disease. Among people who develop 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 bacteria (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 Center for Disease Control and Prevention, and the American College Health Association, Source:

Health History and Treatment Authorization Form Vanderkamp Center _ 337 Martin Road _ Cleveland, NY _

Health History and Treatment Authorization Form Vanderkamp Center _ 337 Martin Road _ Cleveland, NY 13042 315-675-3651 _ vkcenter@vk.org of Program: Please return by: The information on this form is gathered