Week: 1 2 3 4 5 V

08

Camp Berea

Medical Form and Release Form

Camper must have this form to stay at Camp!

Name:_______________________________________ Date of Birth: ____/_____/_____ SS# _____________________

Address _____________________________________________________________________________

^{Street/Box State Zip}

Description of any current health conditions requiring medication, treatment, or special restrictions

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Please indicate any recent medical treatment the camper has received.

_______________________________________________________________________________________

_______________________________________________________________________________________

Date of last tetanus shot: ___/___/____ Please include dates of immunizations the camper has received.

m-Measels_____ m-German Measels_____ m-Mumps_____ m-Polio_____

m-DPT _____ m-MMR______

List any allergies: ____________________________________________________________________________

List any Prescription Medications-(note:all prescriptions must arrive at camp in original containers and be

turned over to Camp staff at registration with clear instructions for dispensing on bottle.)

(IMPORTANT:see back of sheet for inhalers, epi pens, or other self administered medication.)

___________________________________________________________________________________________

___________________________________________________________________________________________

Insurance Company Name: ________________________________ Policy Number:_______________________

Name on Policy:________________________ Parent or Guardian Names ______________________________

Parent number (home) ___________________ (work):______________________

Alternative Contact: ______________________ Number _____________Relationship to Camper:_________

Consent and Release Form

I understand that in the case of emergency or illness, every effort will be made to contact me or the alternate contact person I have indicated. I hereby give consent for any necessary treatments to be administered to

___________________________________. I release and agree to indemnify Camp Berea and any of its representatives from all claims, damages, actions, or causes of action arising therefrom. I agree that my child is in good health other than any condition indicated above and grant permission for him/her to participate in all camp activities unless I have indicated otherwise on this form. I understand that Camp Berea may use my child’s likeness in a photograph or video to promote camp but they will not release my child’s full name or address without my permission.

Date:____/_____/______ Parent or Guardian:______________________________________________

Self-Administered Emergency Medication

New state law requires that we have prior written approval from a camper’s primary health care provider and parent or guardian. If your camper has an inhaler, epi pen, or other emergency medication that they carry with them, please make sure you and your health care provider fill out the form below. The applicable state law follows.

PRIMARY HEALTH CARE PROVIDER FORM

As the primary health care provider for ______________________________________, during his/her time at Camp Berea, ^{Camper Name}

the above camper is permitted to have readily available (carry or possesses outside of the regular supervision of the camp’s health staff) and self-administer as medically necessary: (circle all that apply or list)

A. Asthma Inhaler

B. Epinephrine Pen

C. Other (please list) __________________________________

I have read the State of Maine law below and confirm that the camper has the knowledge and the skills to have readily available and safely self-administer the indicated emergency medication in camp.

__________________________________________________ __________

^{Primary Healthcare Provider Signature Date}

PARENT PERMISSION FORM

As parent or guardian for ____________________________, during his/her time at Camp Berea, the above camper is permitted to have readily available (carry or possesses outside of the regular supervision of the camp’s health staff) and self-administer as medically necessary the above indicated medication or device.

I have read the State of Maine law below and confirm that the camper has the knowledge and the skills to have readily available and safely self-administer the indicated emergency medication in camp.

__________________________________________________ __________

^{Parent or Guardian Signature Date}

Summary of Maine Law on Self Administration of Emergency Medications

Recreational camps for children; emergency medication. A recreational camp for boys or girls must have a written policy authorizing campers to self-administer emergency medication, including, but not limited to, an asthma inhaler or an epinephrine pen. The written policy must include the following requirements:

A. A camper who self-administers emergency medication must have the prior written approval of the camper’s primary health care provider and the camper’s parent or guardian.

B. The camper’s parent or guardian must submit written verification to the camp from the camper’s primary health care provider, confirming that the camper has the knowledge and the skills to safely self-administer the emergency medication in camp;

C. The camp health staff must evaluate the camper’s technique to ensure proper and effective use of the emergency medication in camp; and

D. The emergency medication must be readily available to the camper.

The full statute may be viewed at: http://janus.state.me.us/legis/statutes/22/title22sec2496.html