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Medical Information Form & Waiver

MEDICATIONS BEING TAKEN

Please list ALL medications (including over the counter or non-prescription drugs) taken routinely. Use of any medication is solely the responsibility of the camper and/or his/her parents/guardian while away from Club property. Please note: Nassau Racquet & Tennis Club employees will not administer any medications, nor will any medications be stored on the premises.



RESTRICTIONS

The following restrictions apply to this individual

Does NOT eat:


Red meat Pork Dairy Poultry Seafood Eggs Nuts
(e.g. what cannot be done, what adaptations or limitations are necessary)

GENERAL QUESTIONS

(Explain “yes” answers below) Has/does the participant:

Had any recent injury, illness, or infectious disease?

Yes     No

Have a chronic or recurring illness/condition?

Yes     No

Ever been hospitalized?

Yes     No

Ever had surgery?

Yes     No

Ever had a head injury?

Yes     No

Ever been knocked unconscious?

Yes     No

Wear glasses, contacts or protective eye wear?

Yes     No

Ever had frequent ear infections?

Yes     No

Ever passed out during or after exercise?

Yes     No

Ever been dizzy during or after exercise?

Yes     No

Ever had seizures?

Yes     No

Ever had chest pain during or after exercise?

Yes     No

Ever had high blood pressure?

Yes     No

Ever had back problems?

Yes     No

Ever had problems with joints (e.g., knees, ankles)?

Yes     No

Use an orthodontic appliance at camp?

Yes     No

Have any skin problems (rash, itching, acne)?

Yes     No

Have diabetes?

Yes     No

Have asthma?

Yes     No

Had mononucleosis in the past 12 months?

Yes     No

Had problems with diarrhea/constipation?

Yes     No

Have problems with sleepwalking?

Yes     No

If female, have an abnormal menstrual history?

Yes     No

Have a history of bed-wetting?

Yes     No

Ever had an eating disorder?

Yes     No

Been treated for emotional issues by a professional?

Yes     No

Ever been diagnosed with a heart murmur?

Yes     No

Which of the following has the participant had?

Measles Chicken Pox German measles Mumps Hepatitis A Hepatitis B Hepatitis C

Please give all dates of immunization below or drop off immunization form from your child's doctor at the Club (please note - immunization records are required before your child may attend camp):

DTP (MM/YY)

TD (tetanus/diphtheria) (MM/YY)

Tetanus (MM/YY)

Polio (MM/YY)

MMR (MM/YY)

or Measles

or Mumps

or Rubella

Heamophilus influenza B (MM/YY)

Hepatitis B (MM/YY)

Vericella (chicken pox) (MM/YY)

TB Mantoux Test

TERMS OF ACCEPTANCE and SIGNATURE

Finally, I understand there is no provision for medication administration at Camp.

Above named Parent or Guardian agrees to the Liability Waiver with this electronic signature.

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