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Lions Camp Crescendo Health/Enrollment Card - 2011
Group: Classic Melodies Performance Institute Date: 6/12-6/17
Name__________________________________________________
Sex: M____ F____ D.O.B.________________________
Home Address________________________________________________
__________________________________________________________
*Ky law requires completion of the Health report and notarized parent signature
All Prescription medications brought to camp must be in original containers.
Please complete the form as accurately as possible in case there is a need for medical treatment.
Does camper have or ever had the following medical conditions, ie. asthma, diabetes, seizures, heart trouble or kidney problems? Yes___No___ If yes please explain fully. * Note: If student has asthma, please attach an action plan from their doctor.
_______________________________________________________________
Is student allergic tro any medication? Yes_____NO______If yes, list____________________________________________________________
List any Chronic or long-term illness___________________________________________________________________
Date last Tetanus injection?_____________Physical restrictions?____________
Pediatrician/Primary Care Physician________________________________
Area Code/Telephone Number___________________________________
Insurance Company_______________Policy#______________________
Please attach copy ( front & back) of your insurance card.
______________________________________________________________
Parental Consent for Non-Prescription Medications:
YOUR consent indicated below allows appropriate Lions Camp Crescendo/Classic Melodies Staff to give over the counter medications to this student as needed during this camp session:
Please check each item Yes or No
_______________________________
Tylenol____Yes____No Iburophen____Yes_____No Aspirin___Yes____No
Tums, Pepto Bismo or Milk of Magnesia ( nausea, upset stomach) ___Yes__NO
Emetrol ( Nausea) ____Yes___NO Imodium A-D ( diarrhea) ___Yes___No
Chloraseptic Spray/Cough Syrup/Cough Drops ( Sore Throat) ___Yes___No
Sudafed ( allergy symptoms) ____Yes ____NO Benadyrl___yes___No
Claritin___Yes___No Swim Ear Drops/Earache relief___Yes ___No
Lotrimin AF ( athletes foot) ___Yes___No, Triple Antibiotic Ointment__Yes__No
Hydrocortisone Cream ( rashes/itching) ___Yes ___N0
Desitin ___Yes___NO Medicated Powder ( chaffing) ___Yes___NO
Aloe with Lidocaine ( sunburn) ___Yes___NO
I, the parent/legal guardian of this student, certify that this student is physically able to participate in CMPI/Camp Crescendo training program. I assume all risk incidental to such participation and hereby waive, release, absolve, idemnify, and agree to hold harmless Lions Camp Crescendo inc. /Classic Melodies Performance Institute, it's employees and officers for any claims arrising out of injury or death to this student.
I hereby give my permission for medical treatment for this student should Lions Camp Crescendo/Classic Melodies Administration feel it is necessary. I understand accidental insurance by Lions Camp Crescendo is included in camp fee, and that I will be responsible for any medical bills not covered by Camp Insurance, including pre-existing conditions.
I hereby agree to release and hold Lions Camp Crescendo/Classic Melodies Staff free and harmless for any claims, demands, or suits for damages from any injury or complication that may result from administration of the medications I have voluntarily marked *yes*.
The student and I understand all of the requirments on this sheet and will comply.
_______________________________________________________
(print Parent Guardian Name)
___________________________________________________________
(parent Guardian Signature) (date)
________________________ _____________________
(telephone-day) (cell phone)
REMINDER: MUST BE NOTARIZED - THANK YOU
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