For 2015 office use: Dates will attend camp: from ______to ______
Child’s Name _____________________________
Shady Side Academy Summer Programs 2015
Health Form/Information
Camper Name:
Birthdate:
Grade as of September 2015:
Male/Female
Allergies: Please describe what the camper is allergic to, reaction, treatment, and medication dosage.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Diet: Shady Side Academy Summer Programs are 100% nut free. We also offer gluten free and vegetarian options. If
you need any dietary accommodations please let us know below.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Special Needs: Please list and describe any special needs your child has such as: different learning styles, emotional
issues, social issues, physical, or psychological issues. If you have doctor’s documentation and would like to provide it
please do so. If you would rather discuss these matters please give our Summer Programs office a phone call at 412447-2230.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
For 2015 office use: Dates will attend camp: from ______to ______
Child’s Name _____________________________
Health History
Please Explain any “yes” answers
Have recurrent/chronic/genetic illness?
yes/no
Had a recent infectious disease?
yes/no
Had a recent injury?
yes/no
Has asthma/wheezing/shortness of breath?
yes/no
Have diabetes?
yes/no
Had/Have seizures?
yes/no
Had fainting or dizziness?
yes/no
Passed out/had chest pain during exercise?
yes/no
Have skin problems?
yes/no
Ever hospitalized/had surgery?
yes/no
Any physical activity restrictions ?
yes/no
Does your child require an aide?
yes/no
For 2015 office use: Dates will attend camp: from ______to ______
Child’s Name _____________________________
Please use the space provided to detail any important health related information that will assist Shady Side Academy’s
Summer Programs in providing a safe and fun summer 2015. Please attach any additional health related information.
Please list any prescription medications that your child takes during the year and summer and reason for taking it.
Please also include if there will be any changes to the dosage or schedule in prescription medications for the summer,
during or after summer program hours. All prescription medications, including epi-pens and inhalers, taken during your
child’s time at Shady Side Academy’s Summer Programs must be documented with the Authorization for Medication
form, which is found on our website and in the confirmation email, and given to the Camp Nurse by a parent or legal
guardian. All medications must be in labeled prescription bottles.
Additional Notes:
1. All children must be 5 years old by June 15, 2015 and potty trained to attend.
2. Please attach an up to date Immunization Form from a Doctor’s office.
For 2015 office use: Dates will attend camp: from ______to ______
Child’s Name _____________________________
Parent/Guardian with legal custody to be contacted in case of illness or injury
Name ______________________Relation to camper ______________________ Cell/Phone _____________
Second Parent/Guardian
Name ______________________Relation to camper ______________________ Cell/Phone _____________
Third Emergency contact person that is able to pick up camper in case of Emergency
Name ______________________Relation to camper ______________________ Cell/Phone _____________
Medical Insurance Information
Insurance Company Name _________________________ Subscriber ___________________________
Policy Number _________________________ Phone Number _________________________________
Child’s Primary Physician ________________________ Phone Number __________________________
PERMISSION FOR MEDICAL TREATMENT
I/we hereby grant permission to Shady Side Academy, its physicians, nurses, and/or trainers to render aid, treatment,
medical or surgical care deemed reasonably necessary to the health and well being of our child. I/we further authorize
the athletic trainers at Shady Side Academy to render any first aid or preventative, rehabilitative, or emergency
treatment deemed reasonably necessary to protect the health and well being of the above named camper. I/we
additionally grant, after every effort has been made to contact me and when necessary for protecting the health and
well being of the above named camper, permission for hospitalization, treatment, or surgery at UPMC Saint Margaret’s
or UPMC Children’s Hospital. The care and treatment of any child is primarily parental responsibility, I understand that
every effort will be made to contact either parent first in case our child becomes ill or injured and I have answered all
questions correctly. I/we have reviewed the Shady Side Academy Summer Programs policies.
_______________________
DATE
X _______________________________________________________
SIGNATURE OF PARENT/GUARDIAN
Please send back to SSA by June 1st in one of the following ways:
Email to summerprograms@shadysideacademy.org
Fax to: 412-968-3213
Mail to:
Shady Side Academy Summer Programs
423 Fox Chapel Road
Pittsburgh, PA 15238