Clarkson University Summer Camp Health Packet 2017 Camp(s) Attending: Dates:

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1 Please print or type all information. Clarkson University Summer Camp Health Packet 2017 Camp(s) Attending: Dates: Camper s Information First Name: Last Name: Address: City: State: Zip Code: Country: Date of Birth: (month/day/year) Cell Phone #: Parent/Guardian Information Name: Address: City: State: Zip Code: Home Phone #: Cell Phone #: Address: CLARKSON UNIVERSITY SUMMER CAMP HEALTH INFORMATION PACKET INSTRUCTIONS Clarkson University works hard to assure the health and safety of its campers. Information regarding camper health is important for attaining this goal. Fill out this packet in its entirety and Return to Clarkson University Events Office. Use this checklist to be sure you have completed all the requirements. 1. Contact information complete and Affirmation signed (page 1) 2. A completed Medical History Questionnaire (page 2) 3. Proof of immunity to measles, mumps and REQUIRED DOCTOR S SIGNATURE (page 3) 4. Proof of Insurance and attached copy of insurance card (page 4) 5. Signed Minor Consent Statement (page 4) 6. Medication Distribution forms and REQUIRED DOCTOR S SIGNATURE (page 5&6) AFFIRMATION I affirm that all of the information recorded in this Packet is true and accurate to the best of my knowledge. Student Signature (or parent/guardian) Date CLARKSON UNIVERSITY, Conferences and Events Clarkson University P.O. Box 5601 Potsdam, New York Fax

2 Medical History Questionnaire Camper Name: DOB: Height: Weight: Sex: Male / female ALLERGIES: Medications: No allergies to medication. PAST MEDICAL HISTORY: Please indicate if you have ever been diagnosed with disorders in the following organ systems if yes provide detail below: Medication allergies (please list - with reaction). Yes No Foods: No food allergies Food allergies (please list - with reaction). Environmental: No environmental allergies. Environmental allergies (pollens, dust, etc ) MEDICATIONS: Please list all herbs, supplements, or vitamins that you take, WITH STRENGTH AND FREQUENCY TAKEN. ANY SURGERIES? (Please list): ANY OVERNIGHT HOSPITALIZATIONS? (Please explain): Explain:_ ANY MAJOR INJURIES? (Please explain): Explain:_ Eye (contact, or glasses, glaucoma) Ear, Nose, Throat Renal (UTI, Kidney stone/infection/failure) Gynecologic (STI, HPV, PID, endometriosis, ovarian cyst) Musculoskeletal (Scoliosis requiring brace or surgery, Broken bone requiring surgery, Strain, Sprain, chronic neck or back pain, chronic tendonitis) Respiratory (Asthma, tuberculosis, cystic fibrosis, sleep apnea) Cancer, Blood, or Lymphatic (Anemia, Leukemia, lymphoma, Sickle cell anemia, DVT/blood clots, Hemophilia/Von Willebrand s disease) Heart (Murmur, palpations, high blood pressure, abnormal rhythm, high cholesterol, rheumatic fever, heart or heart valve surgery, Mitral valve prolapse) Gastrointestinal (Heartburn, ulcer, IBS, constipation, GERD, Hernia, gallbladder, Hepatitis, Crohn s/ulcerative colitis) Neurologic (Concussion, seizures/epilepsy, headache-migraine/cluster/tension, muscle weakness/paralysis, hearing/vision loss) Endocrine (Thyroid, Diabetes type I or II, hormonal, obesity, osteoporosis/weak bones) Skin (Acne, eczema, Psoriasis, skin cancer, shingles/herpes Zoster) Psychiatric (ADD/ADHD, anxiety, cutting self, depression, PTSD, bipolar, suicide attempt, eating disorder, alcohol or drug use, past or present abusive relationship, hospitalization for psychiatric reasons) Other: If yes to any of the above please give the details in the space provided below.

3 Immunization Form ALL Campers MUST provide proof of immunity against measles, mumps, and rubella. Individuals born prior to January 1, 1957 are exempt from this requirement. You may have your health care provider complete this form OR attach an official copy (signed by your medical provider) of your immunization record. Copies of booklets are not accepted as proof of immunization. Camper Name: DOB: Prior Name (if any): Phone/Fax Number: REQUIRED IMMUNIZATIONS Options for Proof of Measles/Mumps/Rubella (MMR): MMR #1 : (month/day/year) MMR #2 : (month/day/year) OR Measles #1 : (month/day/year) Measles #2 : (month/day/year) Mumps #1 : (month/day/year) OR Measles Titer*: (mm/dd/yy) * Must attach copy of titer reports to this form Rubella Titer*: (mm/dd/yy) * Must attach copy of titer reports to this form Mumps Titer*: (mm/dd/yy) * Must attach copy of titer reports to this form THIS FORM MUST BE SIGNED BY A HEALTH CARE PROVIDER TO CERTIFY ITS ACCURACY. Signature and Title of Healthcare Provider Date RECOMMENDED IMMUNIZATIONS Meningitis Vaccine (indicate which given): MCV4 (Menactra ) (mm/dd/yy) MPSV4 (Menomune ) (mm/dd/yy) Hepatitis B Vaccine series: Hepatitis B #1: (mm/dd/yy) Hepatitis B #2: (mm/dd/yy) Hepatitis B #3: (mm/dd/yy) Varicella (Chicken Pox) Vaccine if never had disease: Varicella #1: (mm/dd/yy) Varicella #2: (mm/dd/yy) Tetanus/Diphtheria Booster (within last 10 years): Td Tdap (mm/dd/yy) Human Papilloma Virus (HPV) Vaccine: HPV #1: (mm/dd/yy) HPV #2: (mm/dd/yy) HPV #3: (mm/dd/yy) Hepatitis A Vaccine: Hep A Vaccine #1: (mm/dd/yy) Hep A Vaccine #2: (mm/dd/yy) Printed Name Address

4 To Parents/Guardians of Campers Under Eighteen: In order to procure quickly any emergency care that may be necessary for students and at the same time to protect the health care providers and the institutions involved, it is requested that you sign the consent for emergency treatment below. Be assured that we will make every effort to notify parents at once in the case of serious accidents or illnesses when these come to our attention, but since students often come great distances, this may be slow or impossible even by phone. Your cooperation in this matter therefore is much appreciated. I, pursuant to the authority vested in me as the of Parent Guardian Camper s Full Name _, do hereby authorize the Student Health Center staff at Clarkson University upon consultation with a practicing physician or surgeon to exercise for me and on my behalf, all rights and duties with reference to consenting to appropriate medical, psychiatric, and surgical treatment, anesthetics, medicines and hospitalization, including care and treatment, by any hospital, staff surgeon, physician or radiologist which they deem necessary for the emergency care of my,,. Son - Daughter Camper s Full Name Parent/Guardian Signature_ Date (Month/Day/Year) Proof of Insurance: Health insurance is required for ALL participants, and proof of insurance must be provided. Insurance claims are handled by the family and the respective insurance company. Please attach a copy of the insurance card and prescription card if applicable. Insurance Company: Subscriber s Name: City of Company: ID#: Group#: Relationship to Subscriber:

5 Medication Listing and Distribution: Camper Name: _ All medications are turned over to medical staff upon arrival (except emergency items such as Epi-Pens and inhalers) and are secured and dispensed by Clarkson Medical Staff. All medication (prescription, homeopathic or over-the-counter) must be submitted in original prescription packaging or container to the Health Director at check-in. Aside from emergency medications (such as an Epi-pen or inhaler) your child is not allowed to keep any medications on their person while at camp. In order for our staff to give your child ANY medications you will need to have your child's doctor complete the following section of this form: Health Care Provider Authorization for Medications (prescription and over-the-counter): Authorization for Over-the Counter Medications Distributed by Clarkson Medical Staff Drug Name Dosage Schedule and Indications (not to exceed recommended daily dose) Authorization Comments Tylenol Ibuprofen Benadryl Per label instructions by age/ weight Per label instructions by age/ weight Per label instructions by age/ weight Q4hr prn, for pain or fever > F Q4-6hrs prn, for pain or fever > F Q6hr for allergic reaction Yes Yes Yes No No No Provider Name: Phone#: License#: Address: Parent/Guardian Authorization: I give permission for my child,, to receive the medication(s) as prescribed/authorized above. I understand that my child will have all approved medications administered to them by Clarkson University Medical Staff, and that I am responsible for arranging the administration of medications my camper cannot self-administer prior to his or her arrival on campus with a medical health professional, or under my personal supervision and administration. In order for our staff to give your child any medicines a list of medications the camper is taking is required. Medical staff are available to campers at all times and are first responders to any medical emergency that may take place. The Canton-Potsdam Hospital is located less than 2 miles from Clarkson s campus. 1. The medicine is in its original pharmacy container labeled with the camper s name, medicine name, dosage, and time consumption. Over the counter medications must be provided in the original container and labeled with the camper s name. 2. Clarkson University Staff will keep the medicine in a secure location, and at the appropriate time distribute the medication to the camper. 3. The camper will be observed self-administering the appropriate dose as per the container instructions. 4. Personal Epi-Pens and inhalers must be carried by campers at all times. Clarkson University Staff cannot inject medications, or administer medications in any invasive way. Any medicine which a minor cannot self-administer must be stored and administered by a parent/guardian or a licensed healthcare professional service arranged by the parent/guardian. Please arrange this with Clarkson University Medical Staff prior to arrival. There are some over-the-counter medications available through Clarkson Medical Staff (see listing below). Both parents/guardians AND the health care provider must authorize the dispensing of these medications.

6 Medication Listing and Distribution Continued: Camper Name: _ Prescription and Over the-counter Medications Being Brought to Campus Drug Name Dosage Schedule and Indications Reason Comments Parent/Guardian Authorization: I give permission for my child,, to receive the medication(s) as prescribed/authorized above. I understand that my child will have all approved medications administered to them by Clarkson University Medical Staff, and that I am responsible for arranging the administration of medications my camper cannot self-administer prior to his or her arrival on campus with a medical health professional, or under my personal supervision and administration. Parents: you may also elect to not have any over-the-counter medications administered to your child by signing below: I choose NOT to have our physician write orders for my child. I understand that no over-the-counter medications will be administered to my child. If medications are deemed necessary, I will be contacted to make personal arrangements to do so. PLEASE NOTE: if your child is attending an off-site adventure trip it is strongly recommended that you have your physician complete the above form due to the remote nature of such trips.

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