Camper/Student Health | Norwigian heiratage youth summer camp

Camper/Student Health History

Sons of Norway District Six Language and Heritage Camps

"*" indicates required fields

1Camper/Student

2Parent/Guardian

3Emergency Contacts

4Health Providers

5Immunizations

6General Health History

7Medications

8Allergies

9Parent/Guardian Release Authorization

Camper/Student Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

MM slash DD slash YYYY

Gender*

Male

Female

Non-binary

Other

Please tell us about your camper so that we can appropriately interact with them:

Tell us if there are medical considerations that we need to know about.

Parent/Guardian Name*

First Last

Best Emergency Contact Phone*

Alternate Emergency Phone

Parent/Guardian Email*

A copy of the completed form will be sent to this email address.

Emergency Contacts*

Name

Phone

Relationship

Please provide one or more emergency contacts other than Parent/Guardian. Click on the "+" to add additional contact rows.

Child Release Authorizaiton*

Name

Phone

Relationship

All the above listed individuates are authorized to pick up my child from Camp Trollfjell or Trollfjell Folkehøgskule. (Please include parent(s) and/or guardian(s).

Health Insurance Company*

Policy Number*

Insurance Co. Toll Free Phone

Child's Physician*

Prefix First Last

Physician's Phone*

Child's Dentist*

Prefix First Last Suffix

Dentist's Phone*

Enter the date for the most recent immunizations (Enter January 1, 1915 (1/1/1915) to indicate no immunization) :

DTaP*

MM slash DD slash YYYY

diphtheria - pertussis - tetanus

Hepatitis A*

MM slash DD slash YYYY

Hepatitis B*

MM slash DD slash YYYY

MMR*

MM slash DD slash YYYY

measles - mumps - rubella

Polio*

MM slash DD slash YYYY

Chicken Pox*

MM slash DD slash YYYY

COVID-19*

MM slash DD slash YYYY

If you camper/student has not received a COVID vaccination, enter January 1, 1915 (1/1/1915). We will understand this date to mean no vaccination.

Check all that currently or may apply at the time of Camp. Please describe or explain any checked items.

General Health History*

Asthma

ADD/ADHD

Autism/asperger

Back pain/problems

Bed Wetting

Chest pain during exercise

Chicken Pox

Constipation

Contacts

Diabetes

Diarrhea

Dizziness

Ear Infections

Eating problems/disorder

Fainting

Glasses

Headaches

Head injury

Head lice

Hearing aids

Heart defect/disease

Heart murmur

High blood pressure

Joint pain

Measles

Menstruation

Mononucleosis

Night terrors

Orthodontia

Seizures

Skin problems

Sleepwalking

Tuberculosis

None of the above

Check all that apply.

Explain Asthma*

Explain ADD/ADHD*

Explain Autism/asperger*

Explain Back pain/problems*

Explain Bed Wetting*

Explain Chest pain during exercise*

Explain Chicken Pox*

Explain Constipation*

Explain Contacts*

Explain Diabetes*

Explain Diarrhea*

Explain Dizziness*

Explain Ear Infections*

Explain Eating problems/disorder*

Explain Fainting*

Explain Glasses*

Explain Headaches*

Explain Head injury*

Explain Head lice*

Explain Hearing aids*

Explain Heart defect/disease*

Explain Heart murmur*

Explain High blood pressure*

Explain Joint pain*

Explain Measles*

Explain Mononucleosis*

Explain night terrors*

Explain Orthodontia*

Explain Seizures*

Explain Skin problems*

Explain Sleepwalking*

Explain Tuberculosis*

Has your child had any recent injury, illness or infectious disease?*

Enter "None" or a description.

Has your child had a chronic or recurring illness/condition?*

Enter "None" or a description.

Has your child ever been hospitalized or had surgery?*

Enter "None" or a description.

Has your child ever been knocked unconscious?*

Enter "No" or a description.

Has your child ever passed out during or after exercise?*

Enter "No" or a description.

At the time of Camp, will your child have been out of the country in the last 30 days?*

Enter "No" or list countries.

If you child has been in Mexico within the last 30 days, please state where:*

Enter "No" or list cities.

Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire time at camp. Keep it 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.

Regular Medications*

This camper/student takes NO medications on a routine basis.

This camper/student takes the following medications.

Prescription Medications*

Name of medication

Dosage

Frequency

Specific times taken each day

Reason for taking

List all prescription medications (click on "+" to add additional medications).

Non-Prescription Medications*

Tylenol

Ibuprofen

Benadryl

Pepto Bismol

Chloraseptic

Cough Drops

Calamine Lotion

Hydocortisone Cream

Clortrimazole Cream

None of the above

I authorize the above medications to be given as needed (please check all that you authorized).

Identify any medications taken during the school year that participant does/may not take during the summer:

Name of Medication

Allow / Disallow

Click on the "+" to add additional rows.

List all known allergies:

Medication allergies*

Name of Medication:

Describe reaction and management of the reaction.

Enter "None" if camper/student has no know medical allergies. Click on the "+" to add additional medications.

Food allergies and dietary restrictions*

Food name:

Describe reaction and management of the reaction or notes on restrictions:

Enter "None" if camper/student has no know food allergies or restrictions. Click on the "+" to add additional foods.

Other allergies*

Type of allergy:

Describe reaction and management of the reaction.

Include insect stings, hay fever, asthma, animal dander, poison oak/ivy etc. Enter "None" if camper/student has no know allergies. Click on the "+" to add additional items.

This health history is correct, so far as I know, and the person herein has permission to engage in all prescribed program activities. I give permission to the Sons of Norway District Six Language/Heritage Camp to order X-Rays, routine tests and treatment for the health of my child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Sons of Norway District Six Language/Heritage Camp to hospitalize, secure proper treatment for and to order injection and/or anesthesia and/or surgery for my child named above.

Signature*

Sign here using mouse or digital pen.