23970 North Elm Road, Lincolnshire, Illinois 60069 (847) 634-3168 Fax 634-8262
CAMPER HEALTH HISTORY/MEDICAL EXAM FORM To be completed by parent/guardian and pediatrician and must be on file at camp prior to first day. Section A – To be completed by parent/guardian
Name_____________________________________________ Birth Date____/____/____
Home Address_______________________________________________________________________________
General Questions
1. Had any recent injury, il ness, or infectious disease?
15. Ever had back problems? .……………….
2. Have a chronic or recurring illness/condition? .
17. Require an orthodontic appliance? ………
18. Have any skin problems (e.g. itching, rash
7. Ever been knocked unconscious? .……………
8. Wear glasses, contacts or protective eye wear? ….
21. Had mononucleosis in the past 12 month?
9. Ever had frequent ear infections? ……………………
22. Had problems with diarrhea/ constipation?
10. Ever passed out or became dizzy from exercise? …
11. Ever had seizures? …………………………………….
12. Ever had heart trouble? ………………………….….
13. Ever been diagnosed with a heart murmur? …….….
26. Ever had emotional difficulties for which
14. Ever been diagnosed with a blood disorder? ……….
Please explain any “yes” answers, noting the number of the question and any other pertinent information?
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I authorize Tamarak Day Camp medical personnel to give the following over-the-counter medication(s) to my child as needed. Notification wil be provided if dispensed. Parent Guardian Authorizations: This health history is correct and complete as far as I know and the person herein described has permission to engage in al camp activities except as noted. Signed___________________________ Printed ____________________________ Date _______________ Section B – To be completed by physician (including back side) Immunizations are current to date according to the Illinois Admin. Code no. 665?
Comments___________________________________________________________________________________
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TAMARAK DAY CAMP
23970 North Elm, Lincolnshire, Il inois 60069, (847) 634-3168 Fax (847)634-8262
Health Care Recommendations by Licensed Medical Personnel Participant Name_____________________________________________ Birth Date____/____/____
I have examined the above camp participant. Date of examination ____/____/____ BP_______ Weight ______ Height _______
is not able to participate in an active camp program. The applicant is under the care of a physician for the following conditions ______________________________________
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Current treatment at the time of this report includes__________________________________________________________
______________________________________________________________________________________________________ Recommendations and Restrictions at camp Treatment to be continued at camp__________________________________________________________________________
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Any medical-prescribed meal plan or dietary restrictions _________________________________________________________
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Description of any limitation or restriction on camp activities_______________________________________________________
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Additional information for health care staff at the camp___________________________________________________________
______________________________________________________________________________________________________ Food Allergies: No If, Yes, a “Food Allergy Action Plan” must be completed prior to camp. Medication Allergies (list)________________________________________________________________________________
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Other Allergies (list) – insect stings, hay fever, asthma, etc. Include medications provided at camp office.
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______________________________________________________________________________________________________ This person takes medication on a routine basis
Medication #1________________________________ Dosage & Times day________________________________________
Reason for taking _______________________________________________________________________________________
Medication #2________________________________ Dosage & Times day________________________________________
Reason for taking _______________________________________________________________________________________
Attach additional pages for more medications. Identify any medications taken during the school year the participant does/may not take during the summer
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______________________________________________________________________________________________________ Additional information about the participants behavior, physical, emotional, or mental health about which the camp should be aware. ______________________________________________________________________________________________________
______________________________________________________________________________________________________ Signature of Licensed Medical Personnel_______________________________ Printed ____________________________ Date _______________ Address_______________________________________________________________ Phone _________________________
O Conselho do Governo, reunido no dia 26 de março de 2013, na Calheta, no âmbito da visita estatutária à ilha de São Jorge, tomou as seguintes deliberações: 1. Aprovar a atribuição de um apoio financeiro à Câmara Municipal da Calheta correspondente à componente não comparticipada por fundos comunitários das obras de reabilitação da rede viária municipal do concelho afetada pelas
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