/ / Name (print clearly) Session/Program Birth Date M/F Immunizations Please send us a copy of your child s current health-care provider or state or local government immunization record. The New York Department of Health requires us to collect each camper s immunization record annually. Starred (*) immunizations must include date to meet ACA Standard. Immunization Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Latest DTap or TDaP Diphtheria, tetanus, pertussis Tetanus, Pertussis booster* (dt) or (TdaP) MMR Mumps, measles, rubella IPV Polio HIB Haemophilus, influenza type B PCV Pneumococcal Hepatitis B Hepatitis A Chicken Pox Varicella MCV4 Meningococcal meningitis H1N1 Swine Flu Flu Shot you Which have of previously the following has the camper had? Measles Chicken Pox TB Mantoux Test German Measles Date: Mumps Results: Hepatitis A Negative Hepatitis B Positive Hepatitis C If any of the immunizations listed above have not been received, please explain why in box below. If you completed an exemption form for your state or school, please mail a copy to the camp. This immunization history is correct. I understand and accept the risks to me (or my child) if not fully immunized: / / Signature (Parent/Guardian if under 18) Print Name Date Return to the Registrar c/o Quinipet Camp & Retreat Center by June 1st PO Box 549, Shelter Island Heights, NY 11965 cqregistration@nyac.com FAX (631) 760-8270 PHONE (631) 749-0430
/ / Name (print clearly) Session/Program Birth Date M/F Physician s Examination This examination should be performed within 12 months of arrival at camp. Examination for some other purpose within this period is acceptable. Examination is for determining fitness to engage in strenuous activity. Height Weight Heart Blood Pressure Hct/Hgb Test (if appropriate) Urinalysis Health Assessment Please rate the following: Eyes Ears Nose Throat Extremities Glasses Lungs Genitalia Abdomen Hernia Posture Skin V Satisfactory X Not Satisfactory O Not Examined Date of last tetanus shot: Are immunizations up to date? Yes No General Appraisal Please address any concerns from above. Allergies List any allergies the applicant May have, including: Food Insects Medicine Seasonal/Environmental Restrictions List restrictions on the camper at camp, including: Special Diets Current Medications Swimming/Diving Strenuous Activity I have examined the person herein described and have reviewed the health history. It is my opinion that this person is physically able to engage in camp activities, except as noted above. I examined the applicant today Yes No, date of exam: / / Doctor Signature Doctor Print Name Date ( ) Medical Office Address Phone Return to the Registrar c/o Quinipet Camp & Retreat Center by June 1st PO Box 549, Shelter Island Heights, NY 11965 cqregistration@nyac.com FAX (631) 760-8270 PHONE (631) 749-0430
/ / Name (print clearly) Session/Program Birth Date M/F Medication Authorization Complete this form with a doctor if your child is bringing medication* with them to camp. *A Medication is any Rx, OTC, vitamins, natural remedies, or other substance to maintain and/or improve health. Remember to include any inhalers and/or EpiPens. All medications brought to camp must be in original packaging with original labels. Parent/Guardian: No, my child will not bring medication* with them to camp (STOP! you do not need to fill out this form). Yes, my child will take the medication(s)* listed below while attending camp. I authorize Quinipet Camp & Retreat Center to administer medication to my child as described below by the doctor/authorized prescriber. I understand that any changes in medication taken by my child will require a new Medication Authorization. / / Parent/Guardian Signature Print Name Date Doctor/Authorized Prescriber s Order: Prescriber, the Parent/Guardian of the Camper named above has indicated the need for prescription medication while at camp. If more space is required, complete a second form. Medication Name Dose / Method / Frequency Reason Please write any additional information regarding medications and this camper (allergies, side effects, reactions): The following non-prescription medications are stocked at Quinipet Camp & Retreat Center s Nurse s Station and are used on an as needed basis to manage illness and injury. Cross out any of the following medications the camper should NOT be given (This also appears on the Health History Form, please check that they match): ADVIL (Ibuprofen), ALOE VERA GEL, ANTACID (Calcium Carbonate), BENADRYL (Diphenhydramine), CALADRYL, CALAMINE LOTION, CLARITIN (loratadine), DRAMAMINE (Meclizine Hydrochloride), HYDROCORTISONE CREAM 1%, IMODIUM (Loperimide), LOTRIMIN CREAM (Miconazole), MIDOL (Acetaminophen, Caffeine, Pyrilamine), MUCINEX (Guaifenesin), PINK BISMUTH (Bismuth Subsalicylate), ROBITUSSIN DM (Guaifenesin, Dextromethorphan), SUNSCREEN, SWIM-EAR (Isopropal Alcohol, Glycerine), TYLENOL (Acetaminophen), VISINE T (Tetrahydrozoline HCL), ZYRTEC (Cetirizine) / / Prescriber Signature Prescriber Print Name Date ( ) Medical Office Address Phone Return to the Registrar c/o Quinipet Camp & Retreat Center by June 1st PO Box 549, Shelter Island Heights, NY 11965 cqregistration@nyac.com FAX (631) 760-8270 PHONE (631) 749-0430
RELIGIOUS EXEMPTION TO IMMUNIZATION FORM PARENT/GUARDIAN STATEMENT Name of Camper Name of Parent(s)/Guardian(s) Camp Name This form is for your use in applying for a religious exemption to Public Health Law immunization requirements for your child. Its purpose is to establish the religious basis for your request since the State permits exemptions on the basis of a sincere religious belief. Philosophical, political, scientific, or sociological objections to immunization do not justify an exemption under Department of Health regulation10 NYCRR, Section 66-1.3 (d), which requires the submission of: A written and signed statement from the parent, parents, or guardian of such child, stating that the parent, parents or guardian objects to their child s immunization due to sincere and genuine religious beliefs which prohibit the immunization of their child in which case the principal or person in charge may require supporting documents. In the area provided below, please write your statement. The statement must address all of the following elements: 1. Explain in your own words why you are requesting this religious exemption. 2. Describe the religious principles that guide your objection to immunization. 3. Indicate whether you are opposed to all immunizations, and if not, the religious basis that prohibits particular immunizations. You may attach to this form additional written pages or other supporting materials if you so choose. Signature: I hereby affirm the truthfulness of the forgoing statement and have received and reviewed the informational immunization materials provided to me by my child s school. Signature of Parent/Guardian Date
QUINIPET CAMP AND RETREAT CENTER F-'Ai T H II cj \1,T, Dear Parent Guardian, January 16, 2016 I am writing to inform you about meningococcal disease, a potentially fatal bacteria 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 (NYSPHL)was amended to include 2167 requiring overnight children's camps to distribute information about meningococcal disease and vaccination to the parents or guardians of all campers who attend camp for 7 or more nights. This law became effective on August 15, 2003. 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. Casesof meningitis among teens and adults 15 to 24 years of age have more than doubled since 1991. The disease strikes about 3000 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 account for nearly two thirds of meningitis casesamong teens and young adults. Information about the availability and cost of the vaccine can be obtained from your health care provider. Quinipet Camp & Retreat Center is required to maintain a record of the following for each camper: A response to receipt of meningococcal meningitis disease and vaccine information signed by the camper's parent or guardian; AND information on the availability and cost of meningococcal meningitis vaccine (Menomune or Menactra); AND EITHERA 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 camper's parent or guardian. Please review the enclosed materials, and complete the Meningococcal Vaccination Response Form and return it along with your child's Health Form no later than June lsi Sincerely,!~J!~ I lenn~er Martin Registrar PHONE: 631 749 0430 INFO@QUINIPET.ORG FAX: 631 749 3403 WWW.QUINIPET.ORG POST OFFICE Box 549 SHELTER ISLAND HGTS. NY 1 1965
QUINIPET CAMP AND RETREAT CENTER i l F'AlTH H,;:..(; F Quinipet Camp & Retreat Center 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. CHECK ONE o My child has had the meningococcal meningitis immunization (Menommune, Menactra, etc.) within the past 10 years. Date received: (Note: The vaccine'sprotection lasts for approximately 3 to 5 years. Re-vaccination may be considered within 3-5 years.) o 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 will NOT obtain immunization against meningococcal meningitis disease. o I have read, or have had explained to me, the information regarding meningococcal meningitis disease but my child is not old enough to receive this vaccination. SIGN BELOW Signed: Date: _ (Parent/Guardian) Camper's Name: Date of Birth: _ Mailing Address: _ Parent/Guardian e-mail (optional): _ PHONE: 631 749 0430 INFO@QUINIPET.ORG FAX: 631 749 3403 WWW.QUINIPET.ORG POST OFFICE Box 549 SHELTER ISLAND HGTS, NY 1 1965
NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Communicable Disease Control Meningococcal Disease 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) caused by the meningococcus germ. Who gets meningococcal disease? Anyone can get meningococcal disease, but it is more common in infants and children. For some adolescents, such as first year college students living in dormitories, there is an increased risk of meningococcal disease. Every year in the United States approximately 2,500 people are infected and 300 die from the disease. 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 meningococcal meningitis is prevalent. How is the meningococcus germ spread? The meningococcus germ is spread by direct close contact with nose or throat discharges of an infected person. 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. 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. Should people who have been in contact with a diagnosed case of meningococcal meningitis be treated? Only people who have been in close contact (household members, intimate contacts, health care personnel performing mouth-to-mouth resuscitation, day care center playmates, etc.) need to be considered for preventive treatment. Such people are usually advised to obtain a prescription for a special antibiotic (either rifampin, ciprofloxacin or ceftriaxone) from their physician. Casual contact as might occur in a regular classroom, office or factory setting is not usually significant enough to cause concern. Is there a vaccine to prevent meningococcal meningitis? In February 2005, the CDC recommended a new vaccine, known as Menactra TM, for use to prevent meningococcal disease. The previous version of this vaccine, Menomune TM, was first available in the United States in 1985. Both vaccines are 85% to 100% effective in preventing the 4 kinds of the meningococcus germ (types A, C, Y, W-135). These 4 types cause about 70% of the disease in the United States. Because the vaccine does not include type B, which accounts for about one-third of cases in adolescents, it does not prevent all cases of meningococcal disease. Is the vaccine safe? Are there adverse side effects to the vaccine? Both vaccines are currently available and both are safe and effective vaccines. However, both vaccines may cause mild and infrequent side effects, such as redness and pain at the injection site lasting up to two days. Who should get the meningococcal vaccine? The vaccine is recommended for all adolescents entering middle school (11-12 years old) and high school (15 years old) and all first year college students living in dormitories. Also at increased risk are people with terminal complement deficiencies or asplenia, some laboratory workers and travelers to endemic areas of the world. However, the vaccine will benefit all teenagers and young adults in the United States. What is the duration of protection from the vaccine? Menomune"IN, the older version, requires booster doses every 3 to 5 years. Although research is still pending, the new vaccine, Menactra T10I, will probably not require booster doses. 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. P:\SecIions\Community Health\CAMPs\Meningococcal\Meningococcal Fact sheet 200S.doc 312005
HEALTH FORM FOR UNITED METHODIST CAMPS, NEW YORK CONFERENCE Photocopy of front and back of health insurance card must be attached to this form. Front Back