Medical Pre-Consent Form

Date

Name of Child

Date of Birth

This address will receive a confirmation email

Phone

Home Address

Emergency Contact

Emergency Contact Phone

Emergency Contact Address

Child's Physician

Physician's Phone

I authorize healthcare personnel to treat the above child in an emergency while attending and being cared for by the Fairmount Camp staff during the registered camp. I also authorize Fairmount camp to administer my child’s daily medications and the checked over the counter medications on page 2. Basic treatments such as saline eye drops, cough drops, calamine lotion, triple antibiotic ointment and Vaseline may be administered by camp staff as needed.

(signature of parent or guardian)

By checking this box I consent to the above statement and that my typed name above can be used as my signature.

I Consent

Medications:

Daily medications your child will take at camp: (Medications must be in their original bottle and within date)

Parents please complete this portion: Include daily dose and time of day for each dose of each medication

Dose and time of day to take:

Check each over the counter medication that you are ok for your child to receive while at camp:

Hydrocortisone cream Tylenol Ibuprofen Benadryl Tums Mucinex Chloraseptic throat spray

Please provide dosage information for each over the counter medication you indicated was OK for your child to take as needed while at camp:

Medical Information:

Allergies and or reactions:

Date of last tetanus booster:

Has your child had any surgeries?

Yes No

List surgeries:

Chronic or existing diseases or medical problems

Is your child being treated, or has your child ever been treated, for any mental health concerns including, but not limited to, behavior issues, suicidal ideation, addiction, depression, anxiety, etc.?

Yes No

If yes, please explain the concern and/or treatment, if applicable.

Within the last 24 hours have you had?

Vomiting

Yes No

Diarrhea

Yes No

Fever

Yes No

Sore throat

Yes No

Sinus congestion

Yes No

Runny nose

Yes No

Other

Yes No

If other, please explain:

Are you being treated for:

Fracture

Yes No

Sprain

Yes No

Skin infection:

Yes No

Other infections:

Yes No

If yes to any above, please explain:

Have you been out of the country within the past 30 days?

Yes No

Have you tested positive for COVID 19 in the past 90 days?

Yes No

Insurance Information:

Medical Insurance Carrier:

Holders name:

I.D. Number:

Benefit code:

Account number:

** The policy of the camping program states that in case of an accident that requires doctor or hospital care, the family insurance coverage is the

primary coverage and the camp’s insurance is the secondary.**

THIS SECTION FOR NURSE'S USE ONLY

Dorm #_______________
Counselor_______________________________________
Room #_____________________

Campus nurse printed name________________________________
Nurse signature________________________________
Date____________________

Medical Pre-Consent Form

Description

Please Fix the Following