GOLD COAST PLASTIC SURGERY, LLC SURGERY MEDICATIONS Aspirin, aspirin-related products, ALL herbal products and Vitamin E must not be taken during the two weeks prior to and after surgery because they increase bleeding. For this reason, it is very important that contents of any “over the counter preparations” are checked carefully prior to their use. Many headache preparat
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Form packThe Parent Pack receipt form lets us know that you have received and understand the contents of this package. The Health Form is required by NJ State Law and does not require visiting a doctor. Immunization information must be filled out in full; children will not be allowed to attend until all appropriate information is provided. Waivers for persons requesting exemptions from medical examinations or medical treatment must be requested. Please be sure to inform the camp directors with any changes in emergency or health information #'s that occur over the summer. If your child requires medication during the camp day, complete the enclosed form and have it signed by your physician. Medications must be sent in original prescription containers. No plastic baggies or other containers! You must authorize the camp health director to administer over the counter medications and suntan lotion by signing attached form. Sun block is unable to be applied without signed parent authorization. Parents will be contacted prior to the medication being administered when possible. OPTIONAL FORMS (DEPENDING ON CAMPERS NEEDS) AFTER CAMP CARE AUTHORIZATION SHEET (Mandatory for After Campers Only) Only needs to be completed if your child is attending the after care camp program. Only for children 10 years of age or older, or sibling of older child. PLEASE PRINT & WRITE LEGIBLY ON ALL FORMS AND INCLUDE ALL INFORMATION. EXTRA FORMS ARE AVAILABLE AT THE YMCA OF MONTCLAIR FRONT DESK. I have read the Parent Pack statement enclosed and understand the rights I have as a parent of an enrolled child in this program. _________________________ ********************************************************* New Jersey State Law requires a medical form on file in our office before the child attends our program. If parents can not be reached in an emergency, the YMCA will contact the local Rescue Squad and will take your child to the nearest hospital. Continued efforts will be made to reach you. I, individually and on behalf of my minor child(ren), hereby release and hold the YMCA of Montclair, its assigns and successors, its directors, officers, volunteers, and/or others acting on its behalf harmless from all claims that I/we may have arising from activities that I/we may be involved in with the YMCA. I expressly and specifically assume any and all risk of injury, illness, death, or property damage resulting from my/our YMCA activities. I hereby give permission for emergency medical treatment to be administered as deemed appropriate. I understand that the YMCA does not carry insurance to cover injuries and losses that may befall me/us. HAVING READ, UNDERSTOOD, AND AGREED WITH THESE TERMS, I HAVE EXECUTED THIS RELEASE, TO BE EFFECTIVE IMMEDIATELY. _______________________________________________ Dates will attend camp: from ______________to_____________ Camper Name: _____________________________________________________________ Developed and reviewed by: American Camp Association, Male Female Birth Date ____________ Age on arrival at camp: ________ American Academy of Pediatrics Council on School Health, & To Parent(s)/Guardian(s): Please follow the instructions below. Attach additional information if needed.
Mail this form to the address below by _______ (date)
Complete pages 1, 2 and 3 of this form (FORM 1) and make a copy.
Send the original, signed FORM 1 to camp by the requested date.
Complete the top of FORM 2 (CAMPER HEALTH-CARE RECOMMENDATIONS) and provide the
copy of FORM 1 with FORM 2 to your child’s health-care provider for review and completion.
After it has been completed and signed by your child’s health-care provider, return FORM 2 to
camp by the requested date.
Camper Home Address: ______________________________________________________________________________________________________ Parent/guardian with legal custody to be contacted in case of illness or injury: Name: ____________________________ to Camper: ________________Preferred Phones: (______) ________________(______)_________________ Home Address: _____________________________________________________________________________________________________________ (If different from above) Street Address Second parent/guardian or other emergency contact: Name: ____________________________ to Camper: ________________Preferred Phones: (______) ________________(______)_________________ Additional contact in event parent(s)/guardian(s) can not be reached: Name(s): __________________________ to Camper: ________________ Preferred Phones: (______) ________________(______)_________________ Allergies: No known allergies. This camper is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other
(Please describe below what the camper is allergic to and the reaction seen.)
This camper eats a regular diet. This camper eats a regular vegetarian diet. This camper has special food needs. (Please describe below.)
I have reviewed the program and activities of the camp and feel the camper can participate without restrictions. I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations. (Please describe below.)
Medical Insurance Information:
This camper is covered by family medical/hospital insurance Yes No Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable.
Insurance Company______________________________ Policy Number___________________________ Subscriber_____________________________________ Insurance Company Phone Number (______) ___________________ Parent/Guardian Authorization for Health Care:
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in
all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests,
and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my
permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on
this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a
copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.
Parent/Guardian __________________________________________________________________Date: to Camper: _______________________ If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance. Page 1/4
Camper Name: ________________________________________________ Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Immunization History: Provide the month and year for each immunization. Starred ( ) immunizations must be current. Copies of immunization forms
from health-care providers or state or local government are acceptable; please attach to this form.
(chicken pox) Date: Meningococcal meningitis
If your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not
being fully immunized.
Parent/Guardian: ______________________________________________________________Date: to Camper: __________________________ Medication:
This camper will not take any daily medications while attending camp. This camper will take the following daily medication(s) while at camp: "Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Please review camp
instructions about required packaging/containers. Many states require original pharmacy containers with labels which show the camper’s
name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp.
Lunch Dinner Bedtime Other time:_____________ Lunch Dinner Bedtime Other time:_____________ Lunch Dinner Bedtime Other time:_____________
The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury.
Cross out those the camper should not be given.
Diphenhydramine antihistamine/allergy medicine (Benadryl) Dextromethorphan cough syrup (Robitussin DM) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Copyright 2008 by American Camping Association, Inc. NON-PRESCRIPTION MEDICATION AUTHORIZATION I ____________________________, hereby give permission for the YMCA of Montclair Camp at the Lake to administer the following over-the-counter medications if the Camp’s Health Care Provider deems it necessary. Dosages will be administered according to directions on the original container, unless a physician directs otherwise. Upset Stomach . . . . . . . Pepto Bismol Sun Burn Prevention. . . . . . . Sun Block _______________________ _____________________ PRESCRIPTION-MEDICATION AUTHORIZATION AND INSTRUCTION All Medications must be supplied in the original prescription bottle labeled with child's name, date, medication, and dosage. Please give to the bus counselor. Do not pack in child’s backpack. Parent/Guardian Permission: Date: ________________________ Camper's Name: _______________________Village/Age: _____________________ Sessions: _________ Address: ____________________________________________________________________________ Phone # :(_______) __________________________ Name of Medication: _______________________________________________________ I hereby grant permission for the YMCA of Montclair Camp at the Lake to supervise the prescription medication routine below prescribed for the above named child. Amount of Medication: ____________________________ Administration Times: _____________________________ ________ _________________________________________________________________________________ Signature of Parent/Guardian Village________________________________________ WALK HOME PERMISSION SLIP (Optional Form) I ___________________________________ give permission for _______________________________ to walk home from his/her assigned bus stop. My child is over 10 years of age. Camper’s Name: ___________________________ Birth date: ________________________________ Village/Age: ______________________________ ________________________________________ THE YMCA of MONTCLAIR IS NOT RESPONSIBLE FOR YOUR CHILD ONCE THEY WALK HOME PERMISSION SLIP (Optional Form) I ___________________________________ give permission for _______________________________ to walk home from his/her assigned bus stop. My child is over 10 years of age. Camper’s Name: ___________________________ Birth date: ________________________________ Village/Age: ______________________________ ________________________________________ THE YMCA of MONTCLAIR IS NOT RESPONSIBLE FOR YOUR CHILD ONCE THEY (Fill out only if in After Care Camp Program at Hillside School) YMCA of MONTCLAIR CAMP AT THE LAKE AFTER CARE CAMP PROGRAM Child's Name: ____________________________ Address: __________________________________________________________________ Parent’s Name: __________________________ Parent’s Name: ___________________________ Work Phone #:___________________________ Work Phone #:___________________________ Phone #:_______________________________ Phone #:_______________________________ Relation to Child: _________________________ Relation to Child: _________________________ Person authorized to pick-up from After Camp Care: (ID Necessary) Relation: ______________________________ Relation: ________________________ After Camp pick-up is by 6:30 PM. If you are unable to be at the Hillside School by that time, please make arrangements for one of your authorized persons to pick up your child. I understand that late pick-up after 6:30 PM will entail a late fee of $10.00 per child per 10 minute increments. I understand that my child must be signed out everyday before leaving the Hillside School. I have read the above policies and completed the information needed. _________________________________
A CHECKLIST OF THE FLORA OF STAFFORDSHIREThe previous checklist for the county was prepared by Ian Hopkins: Hopkins, I.J. (1985) Staffordshire Flowering Plants and Ferns . Stoke-on-Trent City Museumand Art Gallery. He used information from E.S. Edees' Flora of Staffordshire (1972 David & Charles) as a basis for frequency assessment with some changes where additional/more recent data