Northeast Rowing Center

Health History and Examination Form
For Children, Youth and Adults Attending Camps
______________________________________________________________________________

Please Print, Complete and Return by June 1st - Thanks
 First 2 pages to be filled in by parent/guardian of minor or by adult camper

Camper
Name ______________________________________________________________________________________________
                         Last                                                            First                                           Initial
 Birthdate _________/_________/________                Sex _____ Age _____
              mo              day             yr                                  m/f
 Parent or Guardian (or Spouse) __________________________________________________________________________

Home Address _______________________________________________________________________________________
                                 Number & Street                                          City                              State            Zip
 Phone (_______)__________ -______________

Business ___________________________________________________________________________________________
                                 Number & Street                                          City                              State            Zip
 Phone (_______)__________ -______________

Emergency Contact
Second Parent or Other Person _________________________________________________________________________

If not available in an emergency, notify:

Name ____________________________________________________________________________________________
                         Last                                                            First                                           Initial

Home Address ______________________________________________________________________________________
                                 Number & Street                                          City                              State            Zip

 Phone (_______)__________ -______________

Important - This Section Must Be Signed/Dated For Attendance

This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted. Authorization for treatment: I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests, treatment, and necessary transportation for me or my child. In the event I can not be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for my child as named above. The completed forms may be photocopied for trips out of camp.

 ► Signature of parent or guardian or adult camper _____________________________________________________ Date ________

I also understand and agree to abide by the restrictions placed on my camp activities.

 Signature of minor _____________________________________________________________________________

Health History: (check and approx. dates)        Allergies: (check)           Diseases: (check and approx. dates)
ð _________ Frequent Ear Infections                 ð Hay Fever                        ð _________ Chicken Pox
ð _________ Heart Defect/Disease                    ð Ivy Poisoning, etc.          ð _________ Measles
ð _________ Convulsions                                    ð Insect Stings                   ð _________ German Measles
ð _________ Diabetes                                         ð Penicillin                          ð _________ German Measles
ð _________ Bleeding/Clotting Disorders         ð Other drugs                      ð _________ Mumps
ð _________ Hypertension                                   ð Asthma
ð _________ Mononucleosis Other (Specify)
ð _________ Psychiatric Treatment

Has this camper ever required any psychiatric counseling or hospitalization?  ð Yes,  ð N

            Explain if yes ______________________________________________________________________________________

Operations or serious injuries (dates) ___________________________________________________________________________

Disability or chronic or recurring illness ________________________________________________________________________

Activities encourage or limited by a physician ___________________________________________________________________

Dietary modifications ______________________________________________________________________________________

Current medications (send with instructions) _____________________________________________________________________

Other diseases or details of above _____________________________________________________________________________

Suggestions on health related information ______________________________________________________________________

Name of family physician _____________________________________________ Phone ____________________

Name of family dentist/orthodontist _____________________________________ Phone ____________________

Date of last physical examination _______/________/_______

Medical Insurance: Carrier ___________________________________________________________ 

                                                      Policy/Group # _____________________________

                                                      Please include a photo copy of insurance card if applicatble

Immunization History
 Required immunizations must be determined locally. Please record the date of basic immunizations and most recent boosters.

Vaccines

     Year of Immunization

Year of      Booster

Diphtheria, Pertussis, Tetanus (DPT)

Tetanus, Diphtheria (TD)

Tetanus

Oral Polio (Sabin) TOPV

Injectable Polio (Salk)

Measles (hard measles, red measles, Rubella

Mumps

Rubella (German measles, 3-day measles

Tuberculin test given (most recent)

Haemophilus influenza b (HIB)

Health Care Recommendations by Licensed Physician

I have examined the above camp applicant within the past two years - ð Yes,  ð No,       Date examined - _______________

In my opinion, the above’s condition   ð does,   ð does not  preclude his/her participation in an active camp program.

Height ______________ Weight ______________ Blood pressure _________________________

The applicant is under the care of a physician for the following condition(s): ____________________________________________

        ___________________________________________________________________________________________________

Current treatment (include current medications): __________________________________________________________________

        ____________________________________________________________________________________________________

Explanation of any reported loss of consciousness, convulsion, or concussion: ____________________________________________

       _____________________________________________________________________________________________________

Does applicant have epilepsy?  ð Yes,  ð No     Does applicant have diabetes?  ð Yes,  ð No

Recommendation and Restrictions While at Camp
 Any treatment to be continued at camp: __________________________________________________________________________

        ____________________________________________________________________________________________________

Any medication to be administered at camp (specific dosages): ________________________________________________________

        ____________________________________________________________________________________________________

Any medically prescribed meal plan or dietary restrictions: ___________________________________________________________

        ____________________________________________________________________________________________________

Any allergies (food, drugs, plants, insects, etc.):_ ___________________________________________________________________

         ____________________________________________________________________________________________________

Additional health information: _________________________________________________________________________________

         ____________________________________________________________________________________________________

Important - This Section Must Be Completed For Attendance

Licensed Physician’s Signature_________________________________________________________________

 Address _________________________________________________________________________ Phone ________________________
                  Number & Street                                City                 State           Zip                                     Area-Number

 Date of form completion: ______________________    * By __________________________________________________________

* Initial if completed by nurse or physician’s assistant

Northeast Rowing Center
P.O. Box 2060
Duxbury, MA 02331
Tel. 781-934-6192
 Email at email@RowCamp.com

Back to Camper Forms & Information page