REGISTRATION

*July 4th Week* AGES 7-12 (Half Day) CAMP HEALTH HISTORY

Restrictions: Camp activities include spending time outdoors, hiking, exploring various habitats (fields, forest, shoreline, Narragansett Bay), playing games, swimming, sailing and other physical activities.

I feel my camper can participate without restrictions.
I feel that my camper can participate with the following restrictions or adaptations.
Please describe below and speak with the Camp Coordinator:
 

All medical information is kept private and confidential. Information is ONLY given to instructors and staff as needed to ensure a safe and fun environment for all campers.

Resident, full-time or seasonal
Relative of a resident
Teach in Jamestown
Rent for any period of time
Live or stay for extended periods (i.e. one week at a time) on a boat that moors in Jamestown?
I have no connection to Jamestown, my child comes for camp.
This information is for internal purposes only. Personal details are never shared.

* Please enter birthdate at time of camp.

CONTACT INFORMATION

MEDICAL INFORMATION

ALLERGIES OR OTHER MEDICAL INFORMATION

Food
Medicine
Bee Stings
The Environment (hay fever, insects, etc.)
Other
 

If a camper has an anaphylactic allergy, e-mail or mail a copy of the camper's allergy action plan, CISFSailing@gmail.com or mail to: 7 Felucca Avenue, Jamestown, RI 02835. We cannot guarantee that any area at camp is allergen-free.

GENERAL HEALTH HISTORY

Check "Yes" or "No" for each statement. Explain "Yes" answers in field provided for each question.

Has/Does the camper:

1. Have recurrent/chronic illness(es)?
Yes
No
2. Had a recent injury/illness/infection?
Yes
No
3. Ever had a head injury or concussion?
Yes
No
4. Have asthma*/wheezing/shortness of breath?
Yes
No
5. Have diabetes?
Yes
No
6. Had seizures?
Yes
No
7. Have severe or frequent headaches?
Yes
No
8. Had fainting or dizziness?
Yes
No
9. Have frequent bloody nose?
Yes
No
10. Have a phobia? (note type/severity)
Yes
No
11. Had mononucleosis during the past year?
Yes
No
12. Ever been treated for Lyme Disease?
Yes
No
13. Ever been stung by a bee?
Yes
No

MENTAL, EMOTIONAL & SOCIAL HEALTH HISTORY

Check "Yes" or "No" for each statement. Explain "Yes" answers below.

Has/Does the camper:

1. Ever been diagnosed with attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)?
Yes
No
2. Ever been treated for emotional/behavioral difficulties, self-harm, or an eating disorder?
Yes
No
3. Speak a primary language other than English?
Yes
No

Please explain "Yes" answers in the spaces above. Contact the Camp Coordinator to provide additional information if needed or fill in space below. To better care for your camper: Please provide any additional information about the camper's behavior or physical, mental, emotional, and social health that you think is important or that may affect the camper's ability to participate in the Camp program (shyness, learning style, etc.) List any strategies used to manage the concern or enhance the camper's ability. This information will only be shared with Sea Adventure Instructors on a need to know basis.

MEDICATIONS AT HOME

This camper does not take medications regularly at home.
This camper takes the following medications at home. (Please describe the medication and condition below.)

MEDICATIONS AT CAMP

This camper will bring the following medications to camp:

Include any medication that the camper may need to take at camp, including vitamins, Lactaid, etc. Attach additional pages if needed. The camper's parent/guardian must supply these medications, labeled with the camper's name, unexpired and in original containers, and bearing specific directions for administering. Prescription medications must have the full pharmacy label. Contact the camp coordinator if a camper takes medication for mental health and the medication or dose has changed within the three months prior to camp.

(prescribed & over-the-counter)
 
 
 
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ASTHMA EMERGENCY MEDICATIONS

This camper does not have asthma emergency medications.
This camper needs asthma medication only for respiratory illness and will not bring it to camp unless a parent/guardian notifies the camp.
This camper will bring asthma medication to camp.
This camper will also bring:
Nebulizer
Spacer

Mail or e-mail a copy of the camper's asthma action plan - CISFSailing@gmail.com or mail to: 7 Felucca Avenue, Jamestown, RI 02835. Contact the camp coordinator if you have any questions.

(prescribed & over-the-counter)
 
 
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ALLERGY EMERGENCY MEDICATIONS

This camper does not have allergy emergency medications.
This camper will bring allergy emergency medication but does not need to have it nearby at all times. The medication may be stored in the medication box in the office
This camper will bring allergy emergency medication and should have it nearby at all times in the camp pack. Camp staff must monitor each dose.
This camper has been trained to administer his/her own EpiPen. (Required for age 5+)
This camper recognizes the onset of an allergic reaction and can notify a camp staff member if symptoms occur.
This camper does not recognize and report the onset of an allergic reaction. Call the Camp Coordinator!
 

Mail or e-mail a copy of the camper's allergy action plan - CISFSailing@gmail.com or mail to: 7 Felucca Avenue, Jamestown, RI 02835 Provide two EpiPens bearing the original pharmacy labels.

(prescribed & over-the-counter)
 
 
+ ADD MED

OTHER

Please use this section to tell us anything that you feel will help your child have a positive experience with at camp; or any medical information or learning strategies that are successful with your child.