Camp Duffield Registration Form (Please print)-page A
Date: _______________
Name of Camper: Last____________________________First_______________________________
Home Address:______________________________________________________________________
Street
City
State
Zip
Home Phone# ________________________Sex _______ DOB: ___/___/____ Grade Completed _____
Parents/Guardians:____________________________________________________________________
Custodial Parent Names
Cell Phone# Mom:_______________________________ Dad:_________________________________
Parents email: ________________________________Camper email:___________________________
Emergency Contact Information: (If unable to reach a parent, someone who is available 24/7)
Contact name___________________________Phone:___________________Relationship___________
Contact name___________________________Phone:___________________Relationship___________
Campers Physician:_________________________________ Phone_____________________________
Physicians Address: ___________________________________________________________________
Street
City
State
Zip
Circle the Camp Attending:
Date of Camp
Camp
Paid in Full by Paid in Full by
May 1st
June 1st
Chipmunks
Parent
July 12-15
Chipmunks
July 12-15
$175
$200
Music
July 12-18
$290
$310
Science
July 12-18
$290
$310
Night Owls
July 19-25
$300
$320
Office Use Only
(Date Received)
__________________________________________________________________________
Signature of parent or guardian
Date
This form must be turned in by June 1st .
Duffield Summer Camps, 280 Warren Ave, Kenmore, NY, 14217
Rev.150116
Camp Duffield Registration Form (Please print)-page B
Date:___________
Name of Camper: ______________________________________________DOB_____/____/______
Has camper traveled outside the country in the past 9 months? _________________________
When/Where ______________________________________________________________________
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Has camper had a recent injury, illness or infectious disease?
Are there any chronic or recurring illness/condition?
Has camper been hospitalized or had any surgery?
Does camper have frequent headaches
Ever had a head injury or been knocked unconscious?
Wear glasses or contacts
Ever had frequent ear infections?
Ever pass out or been dizzy during or after exercise?
Ever had seizures or convulsions?
Ever had chest pains?
Ever had high blood pressure?
Ever been diagnosed with a heart murmur or heart condition?
Ever had back problems?
Ever had joint problems?
Bringing an orthopedic device to camp?
Have any skin problems?
Have diabetes?
Have asthma?
Had mononucleosis in past 12 months?
Had problems with diarrhea/constipation?
Problems with sleepwalking or bed wetting?
If female – abnormal menstrual history?
Ever had a emotional problems for which professional help sought?
Ever had an eating disorder?
Bee sting reactions?
Hay fever or other allergies?
Any other facts we need to know:
Yes
Yes
Yes
Yes
Yes
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Yes
Yes
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Yes
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Yes
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Yes
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Explain yes answers here: _________________________________________
_________________________________________________________________
_________________________________________________________________
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Authorizations: This health history is correct and complete to the best of my knowledge, and the person herein
described has permission to engage in all camp activities except as noted on this form. I hereby give permission
to the medical personnel selected by the Camp Director to secure proper treatment and transportation, for myself
or my child named above if deemed necessary. I also give permission to share their medical information for this
purpose. (This must be signed for camper to attend camp)
____________
Signature of parent or guardian
Date
This form must be turned in by June 1st .
Duffield Summer Camps, 280 Warren Ave, Kenmore, NY, 14217
Rev.150116
Camp Duffield Registration Form (Please print)-page C
Authorization from Parent/Guardian for person to
Consent for treatment of minor patient
I, ________________________________do hereby authorize Camp Duffield Staff to sign for any Medical
Treatment deemed necessary for (print child name) ____________________________, whose birth date
is __/__/_____. This authorization is valid from (date) _________ through and including _____________.
Today’s Date_________________________________________
Parent/Guardian______________________________________________________ Print
Parent/Guardian______________________________________________________ Signature
The person herein described has appeared before me and is known by me or has presented
sufficient identification to prove, that he or she, is indeed, the above individual.
Notary Public Signature/Stamp/Date:
_________________________________________________________________________________
Health Insurance Company____________________________________________________________
Name of insured _________________________________ Relationship to camper ________________
Identification Number _________________________________Group No._______________________
Place of Employment_________________________________________________________________
A photocopy of insurance card is required to attend camp.
Camper Physician:
Phone__________________________
Camper Dentist/Orthodontist:
Phone__________________________
This form must be turned in by June 1st .
Duffield Summer Camps, 280 Warren Ave, Kenmore, NY, 14217
Rev.150116
Physician’s Report page 1
Camp Duffield Health History
Name of Camper: ____________________________________________DOB_____/_____/_____
Date of physical: _____/_____/______ (physical must be within past calendar year)
Has camper been hospitalized within the past 3 years? ________________________________
If yes explain details and dates: _____________________________________________________
Patient’s:
HT ________ WT ________ P ________ BP _______/_______RR ________
PHYSICAL EXAMINATION
SYSTEM
HEAD, NECK
EARS,NOSE,THROAT
LUNGS
HEART
ABDOMEN
GENITALIA
SPINE
EXTREMITIES
NEURO
SKIN
EYES
WITHIN NORMAL
ABNORMAL
REASON
MEDICATIONS
Please list all medications (including over the counter or non prescription drugs) being taken. Bring enough
medication to last the entire time at camp. Keep in original packaging/bottle that identifies the medication, the
prescribing doctor, the dosage and frequency of administration.
MEDICATION
DOSAGE
TIMES
GIVEN
Signature of Physician
REASON
SPECIAL
INSTRUCTIONS
Date_________________
Print Name or stamp _____________________________________________________________
Physician’s Report page 2
This form must be turned in by June 1st .
Duffield Summer Camps, 280 Warren Ave, Kenmore, NY, 14217
Rev.150116
Camp Duffield Health History
Name of Camper: ___________________________________________DOB_____/_____/_____
Date of physical: _____/_____/______ (physical must be within past calendar year)
Immunization History: Provide the month and year for each immunization. All immunizations must be
current. Copies of immunization forms from health-care providers are acceptable; please attach to this form.
Immunization
( List or attach doctors records of immunizations )
DTaP or TdaP_________________________________________________________________
DT or TdaP___________________________________________________________________
MMR________________________________________________________________________
IVP_________________________________________________________________________
HIB_________________________________________________________________________
PCV_________________________________________________________________________
Hepatitis A___________________________________________________________________
Hepatitis B___________________________________________________________________
Varicella_____________________________________________________________________
Meningococcal________________________________________________________________
Influenza____________________________________________________________________
Pertussis_____________________________________________________________________
Allergy Information:
Allergy to:
Dust/Mold
Insect Bites:
Animals:
Latex
Sunscreen
Food:
Food:
Medications:
Medication:
___Does not apply (no allergies)
Reaction:
Treatment:
If child is required to carry an epi pen, you must bring the epi pen with your physicians Rx
and contact Mary Owens as we need additional forms filled out.
Signature of Physician
Date_________________
Print Name or stamp _____________________________________________________________
This form must be turned in by June 1st .
Duffield Summer Camps, 280 Warren Ave, Kenmore, NY, 14217
Rev.150116
Physician’s Report page 3
Camp Duffield Health History
Name of Camper: ___________________________________________DOB_____/_____/_____
OVER THE COUNTER MEDICATION FORM
Your medical doctor must complete this form
I hereby authorize that the following medications may be given to the above named camper at Camp
Duffield after nursing assessment.
Bactine (topical) for minor wound care, first aid as needed
Triple Antibiotic Ointment (topical) for wound healing
Tylenol (oral) as directed on bottle
Ibuprophen (oral) as directed on bottle
Cough Drops for coughing, minor throat irritation as needed
Antacid Tablet (oral) for stomach discomfort
Benydryl (oral or topical) for swelling, hives, or allergic reaction as directed on bottle
Calamine Lotion or Cortaid (topical) for insect bites/bee stings
Visine/ Murine Plus Eye Drops (topical in eye) for minor eye irritation
Other (please describe) ______________________________________________________
_________________________________________________________________________
PHYSICIAN CONSENT
Physician Signature ______________________________________ Date ______________________
Printed Name __________________________________________ License Number ______________
Address ______________________________________________Phone _______________________
City _____________________________ State ________ Zip _______ Fax ______________________
This form must be turned in by June 1st .
Duffield Summer Camps, 280 Warren Ave, Kenmore, NY, 14217
Rev.150116
Physician’s Report page 4
Camp Duffield Health Medication Forms
Name of Camper: ___________________________________________DOB_____/_____/_____
For Prescription Medications:
Any use of prescription drugs must be ordered by the Camper’s Physician and brought in original
container. This form must be completed for each prescription to be administered and signed by the
Camper’s Physician.
For Over-the Counter Medications:
Any additional over-the-counter medication not listed on above form must have specific directions and be in the
original container. This form needs to be completed for these over-the-counter medication the Camper uses.
Please give the following medications to the above named Camper:
Name of Prescription Medication:
______
Dosage of Drug:
Times to be administered:
Length of time drug is to be given:
Print Physician’s Name:
Signature of Physician:
Physician’s Phone No.:
Date:
Name of Over-the-Counter Medication:
Dosage of the Drug:
Times to be administered:
Length of time drug is to be given:
Signature of Parent/Guardian:
This form must be turned in by June 1st .
Duffield Summer Camps, 280 Warren Ave, Kenmore, NY, 14217
Rev.150116