HEALTH HISTORY FORM
Children’s Genius Planet
Health History Forms must be filled out by a parent/guardian. Please complete all pages. Incomplete or unsigned
forms will be returned to you. Please return the completed forms and other documentation via
email:info@childrensgeniusplanet.com or mail to Children’s Genius Planet at
426 Hunnewell St, Needham, MA 02494
In addition to this completed form, the following must be submitted in order to complete your
camper’s health record: Any missing pieces will delay processing.
☐ This health history form (including required signature on page 3)
☐ Copy of child’s most recent physical exam within the past 12 months OR page 4 of this form filled out by a
licensed health care provider
☐ Certificate of immunizations signed by a licensed health care provider
☐ Photocopy of front and back of insurance card
☐ Please keep a copy of the completed form for your records
CAMPER'S NAME:
CAMPER HOME ADDRESS:
BIRTH DATE:
/
/
PARENT / GUARDIAN #1 INFORMATION
PARENT / GUARDIAN #2 INFORMATION
First Name
First Name
Last Name
Street Address
City
Last Name
Street Address (if different from Parent / Guardian #1)
State
Zip
City
Home Phone
Home Phone
Work Phone
Work Phone
Cell Phone
Cell Phone
Email
Email
Employer
Employer
State
Zip
FAMILY EMAIL ADDRESS: (used for confirmations & important updates)
EMERGENCY PHONE NUMBER: (one number where you can be contacted in the event of an emergency)
WHO HAS LEGAL CUSTODY OF THE CAMPER?
Both Parents
Parent/Guardian 1
Parent/Guardian 2
Other
COMMUNICATION: We will be sending confirmations and additional paperwork to the family email address listed. If you prefer to receive
these in the mail, please contact us directly.
PLEASE LIST ADDITIONAL CONTACTS, OTHER THAN PARENTS, THAT WE MAY CONTACT IN THE EVENT OF AN EMERGENCY
AND THAT ARE AUTHORIZED TO PICK UP THE CAMPER. A PHOTO ID IS REQUIRED AT PICK UP.
Name________________________________________
Name ___________________________________
Relationship to Camper
Relationship to Camper ______________________
Best number to be reached at
Best number to be reached at ________________
Email
Email
UNAUTHORIZED PICK UPS REQUIRE DOCUMENTATION. PLEASE ASK US FOR MORE INFORMATION
CAMPER'S PHYSICIAN INFORMATION:
Name:___________________________________________
Phone: ___________________________________
Address: ________________________________________
CAMPER'S DENTIST/ORTHODONTIST INFORMATION:
Name:____________________________________________
Phone: __________________________________
Address: _________________________________________
INSURANCE INFORMATION:
Is the camper covered by family medical/hospital insurance?
☐ NO
☐ YES
Carrier/Plan Name:
Group/Policy Number:
CAMPER'S MEDICAL HISTORY:
The following information must be filled in by the parent/guardian. This information is intended to provide camp health care
personnel with the background to provide appropriate care. Please keep a copy of the completed form for your records. Any
changes to this form should be provided to the camp health personnel upon arrival. Complete information must be provided to
ensure camp is aware of your camper's needs. If "NONE" please indicate that clearly below - do not leave blank.
ALLERGIES: LIST ALL KNOWN.
Medication Allergies:
☐ None
Describe reaction and management of the reaction
Food Allergies:
☐ None
Describe reaction and management of the reaction
Other Allergies:
☐ None
Describe reaction and management of the reaction
RESTRICTIONS:
Explain any limitations to activity (i.e. what cannot be done at all or what adaptations are necessary for participation) ☐ None
Camper does not eat:
☐ red meat
☐ pork
☐ poultry
☐ other: ___________________________________
MENTAL, EMOTIONAL AND SOCIAL HEALTH
Has the camper:
☐ seafood
☐ eggs
☐ dairy products
☐ nuts & nut products
Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD)?
Ever been treated for emotional or behavioral difficulties or an eating disorder?
During the past 12 months, seen a professional to address mental/emotional health concerns?
Had a significant life event that continues to affect the camper's life? (history of abuse, family change, etc.)
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐
☐
☐
☐
No
No
No
No
Please explain any YES answers and describe any current physical, mental or psychological conditions requiring
medication, treatment or special considerations at camp.
Please specify circumstances that you would like to be contacted (i.e. a diabetic who has blood sugar less than 70 or
greater than 250) and briefly describe anything we should know about your child such as disabilities, IEP, etc. Feel free to
attach an- other sheet of paper if more room is needed.
MEDICATIONS:
Please list ALL medications, including over-the-counter or nonprescription drugs taken routinely. Bring enough medication to
last the entire time at camp. Medication must be in the original packaging/bottle that identifies the prescribing physician (if a
prescription drug), the name of the medication, the dosage and the frequency of administration. All medications must be given
to the camp nurse or health care supervisor on the first day at check-in.
☐ None
/
/2015, this person takes the following medications: Identify any medication taken during the school year
☐ As of
that the participant does/may not take during the summer:
Name of Medication
Date Started
Reason for Taking
When is it Given
Amount /Dose
How is it Given
QUESTIONNAIRE:
Has/does the camper:
1. Ever been hospitalized?
2. Ever had surgery?
3. Have recurrent/chronic illnesses?
4. Had a recent infectious disease?
5. Had a recent injury?
6. Had asthma/wheezing/short breath
7. Have diabetes?
8. Had seizures?
9. Had headaches?
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐
☐
☐
☐
☐
☐
☐
☐
☐
No
No
No
No
No
No
No
No
No
10. Wear glasses/contacts?
11. Had fainting or dizziness?
12. Passed out/chest pain during exercise?
13. Have problems with sleepwalking?
14. Ever had back/joint problems?
15. Have a history of bed-wetting?
16. Have problems with diarrhea/constipation?
17. Have any skin problems?
18. Traveled outside USA the past 9 mos.?
Please explain any YES answers in the following space, noting the number of the question:
☐ Yes ☐No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
PARENT/GUARDIAN AUTHORIZATION
This health history is correct and complete to the best of my knowledge. The person herein described has permission to
engage in all camp activities, except noted. I hereby give permission to the camp to provide routine health care, administer
prescribed and over-the-counter medications and seek emergency medical treatment, including ordering x-rays or routine
tests. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. I understand that
I and/or my insurance company are responsible for the expenses incurred. I give permission to the camp to arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the
physician selected by the camp to secure and administer treatment, including hospitalization, for my child. This completed
form may be photocopied as needed.
Signature of Parent/Guardian _________________________________________________________________________
Printed Name _______________________________________________
Date Signed
PAYMENT
A non-refundable, non-transferable $100 deposit per camper PER SESSION is required to hold a spot at camp. The balance of
the tuition is due May 1, 2015.
REFUND POLICY
There are no refunds of the deposit. Refunds of tuition paid minus deposit will only be granted prior to May 1, 2015 with a
written request for a refund. Refunds of tuition may only be considered for serious medical reasons causing camper withdrawal
upon written advice from a physician. Campers who arrive late, depart early or miss days are not granted pro-rated fees of
refunds even if requested before May 1, 2015. No refunds are given for campers who decide they do not like camp, have
minor illness, are homesick, are removed from camp for disciplinary reasons, and/or changes of parent's plans.
Parent/Guardian Initial_________________
Date ______________________________________________________
PHOTOGRAPHY/VIDEO
I hereby authorize the Children’s genius Planet to take, have and use photographs, slides or videos as may be needed for its
records for public relations purposes. Please initial your choice - if denied, please attach a photograph of your child to this application
to ensure we do not photograph him/her while at camp.
Permission Granted_____________________ Permission Denied ___________________________________________
RELEASE
While it is the aim and the responsibility of the Children’s Genius Planet to provide your child with a safe and enjoyable experience, please realize that participation in Summer programs has some inherent risks. I hereby authorize that my child is ready
to experience an active camp setting. I give permission for him/her to participate in all planned camp activities and programs.
I hereby release for myself and my child, our heirs, executors and administrators, and forever discharge the Children’s Genius
Planet its agents, servants, representatives and employees for any injuries, loss, liability, damage or costs which my child may
receive / incur as a result of participation in any program/activity/ service conducted and/or provided by the Children’s Genius
Planet.
I understand that there will be other forms as listed in the family handbook that must be submitted before the camper can
participate in camp. The camper may not participate in camp until all paperwork is received. I will keep a copy of all paperwork for my records and will provide upon request.
Parent/Guardian Signature
Date
________________________