Armada Police Athletic League Camper Health History Form - 2015
Name ____________________________________________________________ Birth Date _____/_____/________
Last
First
Address ___________________________________________________________________________________________
City
Zip
Home Phone ______________________________ Cell Phone ____________________________________
Alternative Number _______________________________________________________________________
Immunization Record: State law requires that all immunizations be up to date.
Please certify that your child’s immunizations are up to date. Indicate last booster __________________
List and describe all allergies. (plants, hay fever, asthma, foods, insect, and medications)
Please Check all that apply: (This information is confidential)
Headaches _____
Fainting ______
Bed Wetting _____
Epilepsy _____
Nightmare _____
Ear Infections _____ Hemophilia _____
Diabetes _____
Hypoglycemia _____ Cramps ______ Broken Bones (within the last 6 months) _____
ADD/ADHD _____
*Behavior Management Issues _____
* Learning Disability _____ *Physical Impairments _____
Nosebleeds ______
Sleep Walking _____
Heart Disease ______
*Impulsive Behavior _____
*Emotional Impairments _____
* Please Explain
_________________________________________________________________________________________________
___________________________________________________________________________________________________
Recent Exposure to contagious disease (ex - chicken pox) ___________________________________________
Routine First Aid: I give permission that routine first aid may be administered to my child by the camp
health director.
Signature of Parent/Guardian _______________________________________________Date ______/______2015
Relationship to child: _____________________________________________
Medication and insurance information on back
Armada Police Athletic League Camper Health History Form - Page 2
Please list all routine medications/mg, the dosage required, and the reason the medication is needed.
(Ex: Allegra, one tablet twice daily, allergies)
All medications must be in their original container.
Medication ____________________
Dosage _______________________ Reason _______________________
Medication ____________________
Dosage _______________________ Reason _______________________
Medication ____________________
Dosage _______________________ Reason _______________________
All medications must be checked in to the nurse including: Tylenol, Motrin, Benadryl, cough drops etc.
Doctor’s Name _______________________________________ Phone ___________________________________
Medical Insurance Carrier ________________________________________________________________________
Name of person who carries this policy. ___________________________________________________________
Policy Number ______________________________Group Number ______________________________________
I HEREBY CERTIFY THAT THE ABOVE HEALTH HISTORY IS AS OF TIS DATE HERE OF, ACCURATE AND
COMPLETE.
Signature of parent/guardian ______________________________________Date _____/_____/2015
LIMITED PURPOSE PWOER OF ATTORNEY: CONSENT TO TREATMENT OF MINOR
MERCY HOSPITAL, CADILLAC, MICHIGAN
Must be signed by a parent or guardian.
1. The undersigned herby appoints the Camp Director, Tim Woelkers, Assistant Directors, Shirley
Frederick, Lindsay Claeys, Nurse, Jamie Wright, and Health Director Sandy Hoxie, power of consent
on our behalf to all emergency treatment and/or medical care (except elective surgery) of
(child’s name ) ___________________________, determined to be necessary or desirable by our child’s
attending physician at the hospital.
2. This power of attorney shall continue until revoked by the undersigned, or for 6 months after its
date, whichever is earlier. Physicians or the hospital’s medical staff may assume and rely on this
authorization as currently in effect during such 6 months period unless notified.
3. The undersigned certify that they have read this power of attorney (or had it read to them) and that
they understand this power of attorney.
Parent/Guardian’s Name ____________________________Signature ____________________________________
Print
Relationship to Child ___________________________________________________Date _______/_______/2015