Clarkson University
Please print or type all information.
Parent/Guardian Information
Camper’s Information
First Name:
Last Name:
Address:
City:
State:
Country:
Date of Birth:
Cell Phone #:
SSN:
Camp Attending:
Name:
Address:
City:
State:
Home Phone
Zip Code:
_
Zip Code:
Cell
(month/day/year)
#:
Phone
#:
E-mail Address:
CLARKSON UNIVERSITY SUMMER CAMP HEALTH INFORMATION PACKET CHECKLIST
Clarkson University works hard to assure the health and safety of its campers. Information regarding camper health is
important for attaining this goal. Please complete this packet and send it to Clarkson University Student Health Services.
Use this checklist to be sure you have completed all the requirements.
1. A signed affirmation statement (page 2).
2. A completed Medical History Questionnaire (page 3).
3. For students born on or after January 1, 1957, proof of immunity to measles, mumps, and
rubella
4. Telephone Consent / Under 18 Consent form
5. Have you submitted your complete health information packet?
AFFIRMATION
I affirm that all of the information recorded in this Packet is true and accurate to the best of my knowledge.
Student Signature (or parent/guardian)
Date
CLARKSON UNIVERSITY, Conferences and Events Email: conferences@clarkson.edu
Clarkson University • P.O. Box 5601 • Potsdam, New York 13699-5601
315-268-6425 • Fax 315-268-7772 • www.clarkson.edu
Medical History Questionnaire
Name:
SSN:
DOB:
Height:
Weight:
ALLERGIES:
Medications:
□ No allergies to medication.
□ Medication allergies (please list - with reaction).
Sex: Male / female
PAST MEDICAL HISTORY:
Please indicate if you have ever been diagnosed with disorders
in the following organ systems if yes provide detail below:
Yes No
_
Foods:
□ No food allergies
□ Food allergies (please list - with reaction).
_
Environmental:
□ No environmental allergies.
□ Environmental allergies (pollens, dust, etc…)
_
MEDICATIONS: Please list all herbs, supplements, or vitamins
that you take, WITH STRENGTH AND FREQUENCY TAKEN.
□ None
□ Yes
_
_
The Health Center is an acute care facility we do not
diagnose or prescribe medication for ADD/ADHD.
If you are currently taking any medication and will
need refills written at the Health Center we will need
documentation and/or testing from your primary
care physician prior to the refill request.
ANY SURGERIES? (Please list):
□ None
□ Yes
_
_
ANY OVERNIGHT HOSPITALIZATIONS? (Please explain):
□ None
□ Yes
Explain:
_
_
ANY MAJOR INJURIES? (Please explain):
□ None
□ Yes
Explain:
_
Eye (contact, or glasses, glaucoma)
Ear, Nose, Throat
Renal (UTI, Kidney stone/infection/failure)
Gynecologic (STI, HPV, PID, endometriosis, ovarian
cyst)
Musculoskeletal (Scoliosis requiring brace or
surgery, Broken bone requiring surgery, Strain,
Sprain, chronic neck or back pain, chronic
tendonitis)
Respiratory (Asthma, tuberculosis, cystic fibrosis,
sleep apnea)
Cancer, Blood, or Lymphatic (Anemia, Leukemia,
lymphoma, Sickle cell anemia, DVT/blood clots,
Hemophilia/Von Willebrand’s disease)
Heart (Murmur, palpations, high blood pressure,
abnormal rhythm, high cholesterol, rheumatic
fever, heart or heart valve surgery, Mitral valve
prolapse)
Gastrointestinal (Heartburn, ulcer, IBS,
constipation, GERD, Hernia, gallbladder, Hepatitis,
Crohn’s/ulcerative colitis)
Neurologic (Concussion, seizures/epilepsy,
headache-migraine/cluster/tension, muscle
weakness/paralysis, hearing/vision loss)
Endocrine (Thyroid, Diabetes type I or II,
hormonal, obesity, osteoporosis/weak bones)
Skin (Acne, eczema, Psoriasis, skin cancer,
shingles/Herpes Zoster)
Psychiatric (ADD/ADHD, anxiety, cutting self,
depression, PTSD, bipolar, suicide attempt, eating
disorder, alcohol or drug use, past or present
abusive relationship, hospitalization for psychiatric
reasons)
Other:
_
If yes to any of the above please give the details in the
space provided below.
_
_
_
_
_
_
_
Immunization Form
ALL Campers MUST provide proof of immunity against measles, mumps, and rubella. Individuals born prior to January 1,
1957 are exempt from this requirement.
You may have your health care provider complete this form OR attach an official copy (signed by your medical
provider) of your immunization record.
Copies of booklets are not accepted as proof of immunization.
Phone/Fax Number: __________________________
SSN#:
Prior Name (if any):
Name:
DOB:
REQUIRED IMMUNIZATIONS
Options for Proof of Measles/Mumps/Rubella (MMR):
MMR #1 :
MMR #2 :
OR
Measles #1 :
Measles #2 :
Mumps #1 :
(month/day/year)
(month/day/year)
(month/day/year)
(month/day/year)
(month/day/year)
OR
Measles Titer*:
(mm/dd/yy)
* Must attach copy of titer reports to this form
RECOMMENDED IMMUNIZATIONS
Meningitis Vaccine (indicate which given):
MCV4 (Menactra™)
MPSV4 (Menomune™)
(mm/dd/yy)
Hepatitis B Vaccine series:
Hepatitis B #1:
Hepatitis B #2:
Hepatitis B #3:
Varicella (Chicken Pox) Vaccine if never had disease:
Varicella #1:
Varicella #2:
Rubella Titer*:
(mm/dd/yy)
* Must attach copy of titer reports to this form
Mumps Titer*:
(mm/dd/yy)
* Must attach copy of titer reports to this form
THIS FORM MUST BE SIGNED BY A HEALTH
CARE PROVIDER TO CERTIFY ITS ACCURACY.
Tetanus/Diphtheria Booster (within last 10 years):
Td
(mm/dd/yy)
Human Papilloma Virus (HPV) Vaccine:
HPV #1:
HPV #2:
HPV #3:
Signature and Title of Healthcare Provider
Date
Printed Name
Address
Hepatitis A Vaccine:
Hep A Vaccine #1:
_(mm/dd/yy)
Hep A Vaccine #2:
_(mm/dd/yy)
To Parents and Guardians of Campers under Eighteen:
In order to procure quickly any emergency care that may be necessary for students and at the same time to protect the
health care providers and the institutions involved, it is requested that you sign the consent for emergency treatment
below.
Be assured that we will make every effort to notify parents at once in the case of serious accidents or illnesses when
these come to our attention, but since students often come great distances, this may be slow or impossible even by
phone. Your cooperation in this matter therefore is much appreciated.
I
, pursuant to the authority vested in me as the
Of__________________________________
Camper’s Full Name
Parent – Guardian
_,
do hereby authorize the Student Health Center staff at Clarkson University upon consultation with a practicing physician
or surgeon to exercise for me and on my behalf, all rights and duties with reference to consenting to appropriate
m e d i c a l , psychiatric, and surgical treatment, anesthetics, medicines and hospitalization, including care and
treatment, by any hospital, staff surgeon, physician or radiologist which they deem necessary for the emergency care of
my,
,
Son - Daughter
_.
Camper’s Full Name
Parent/Guardian Signature
Date
(Month/Day/Year)
Proof of Insurance:
Health insurance is required for ALL participants, and proof of insurance must be provided. Insurance claims are handled
by the family and the respective insurance company. Please attach a copy of the insurance card and prescription card if
applicable.
Insurance Company:
ID#:
Subscriber’s Name:
Group#:
City of Company:
Relationship to Subscriber:
Name:
SSN:
Medication Listing and Distribution:
In order for your child to attend a Clarkson University Summer Camp, a Health History Form must be filled out and turned in upon registration. This history asks for
physical, mental, and medical conditions such as allergies, chronic illness, disabilities, and any other conditions that could impact the camper’s ability to participate in
the program safely. A list of medications the camper is taking is also required. Medical staff are available to campers at all times and are first responders to any
m e d i c a l emergency that may take place. The Canton-Potsdam Hospital is located less than 2 miles from Clarkson’s campus. All medications are turned over
to medical staff upon arrival (except emergency items such as Epi-Pens and inhalers) and are secured and dispensed by Clarkson Medical Staff. A camper’s medicines
may be distributed by medical staff under the following conditions:
1.
The medicine is in its original pharmacy container labeled with the camper’s name, medicine name, dosage, and time consumption. Over the counter
medications must be provided in the original container and labeled with the camper’s name.
Clarkson University Staff will keep the medicine in a secure location, and at the appropriate time distribute the medication to the camper.
The camper will be observed self-administering the appropriate dose as per the container instructions.
Personal Epi-Pens and inhalers must be carried by campers at all times.
2.
3.
4.
Clarkson University Staff cannot inject medications, or administer medications in any invasive way. Any medicine which a minor cannot self-administer must be stored
and administered by a parent/guardian or a licensed healthcare professional service arranged by the parent/guardian. Please arrange this with Clarkson University
Medical Staff prior to arrival. There are some over-the-counter medications available through Clarkson Medical Staff (see listing below). Both parents/guardians AND
the health care provider must authorize the dispensing of these medications.
Authorization for Over-the –Counter Medications Distributed by Clarkson Medical Staff
Drug Name
Tylenol
Ibuprofen
Benadryl
Children’s Mylanta
Dramamine
Dimetapp
Midol
Pepto-Bismol
Robitussin
Tums
Dosage
Per label instructions
by age/ weight
Per label instructions
by age/ weight
Per label instructions
by age/ weight
Per label instructions
by age/ weight
Per label instructions
by age/ weight
Per label instructions
by age/ weight
Per label instructions
by age/ weight
Per label instructions
by age/ weight
Per label instructions
by age/ weight
Per label instructions
by age/ weight
Schedule and
Indications (not to
exceed recommended
daily dose)
Authorization
Q4hr prn, for pain or
fever >
F
Q4-6hrs prn, for pain
or fever >
F
Q6hr for allergic
reaction
BID-TID prn for
stomach upset
Q6-8hrs prn for motion
sickness
Q6-8hrs prn for nasal
congestion/drainage
Q6hr prn for menstrual
cramping and
discomfort
Q30min-1hr prn, for
diarrhea
Q4hr prn, for cough
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Q1hr, prn for upset
stomach related to
indigestion
Yes
No
Comments
Prescription and Over –the-Counter Medications Being Brought to Campus
Drug Name
Dosage
Schedule and
Indications
Reason
Comments
Name:
SSN:
Health Care Provider Authorization for Medications (prescription and over-the-counter):
Provider Name:
Address:
Signature:
Phone#:
License#:
Date:
Parent/Guardian Authorization: I give permission for my child,
, to receive the
medication(s) as prescribed/authorized above. I understand that my child will have all approved medications
administered to them by Clarkson University Medical Staff, and that I am responsible for arranging the administration of
medications my camper cannot self-administer prior to his or her arrival on campus with a medical health professional,
or under my personal supervision and administration.
Signature:
Date: