Medical Form 2024 - Greater Houston

Medical Information & Release Form

Greater Houston Youth Camp

June 10-15, 2024

CAMPER INFORMATION

Camper Name*

First Name

Middle Name (optional)

Last Name

Camper Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Camper Sex*

Camper Date of Birth*

Camper Grade Completed*

(when camp starts)

Camper Age When Camp Starts*

Parent/Guardian Name*

First Name

Initial (optional)

Last Name

Parent/Guardian Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone (Parent/Guardian or Adult Sponsor)*

Parent/Guardian Alternate Phone

Email Address (Parent/Guardian or Adult Sponsor)*

Emergency Contact Name*

First Name

Last Name

Emergency Contact Phone*

MEDICAL INFORMATION REQUESTED

Family Physician's Name

Prefix (optional)

First Name

Last Name

Family Physician's Phone

Name of Insurance Company

Insurance Policy Number

Date of Last Tetanus Shot*

Is Camper Allergic to Tetanus Booster*

Date of Polio Vaccine*

Date of Measles/Mumps/Rubella Vaccine*

Campers with a history of Seizures, diagnosis of Asthma requiring an inhaler, or an Allergy that may require an Epinephrine Pen, must also bring either a Seizure Action Plan Form, Asthma Action Plan Form or Allergy & Anaphylaxis Plan Form (whichever applies) signed by their doctor.

Forms are available at www.altofrio.com or email director@altofrio.com. If your child has one of these plans on file with their school, you could request a copy from the school nurse.

Please give details on any conditions you checked in the previous question.*

ALLERGIES

You have indicated you do not have

food allergies
medicine allergies
bite or sting allergies
seasonal allergies

If you do have one of these allergies, please correct the question above.

Food allergies*

Medication allergies*

Seasonal Allergies*

Bite or Sting Allergies*

MEDICATIONS

PLEASE CHECK THE APPROPRIATE BOX BELOW (Medications)*

I DO NOT have prescription or over-the-counter medications that must be taken at camp. I HAVE ONLY prescription medications that must be taken at camp. I HAVE ONLY over-the-counter medications that must be taken at camp. I HAVE BOTH prescription and over-the-counter medications that must be taken at camp.

select only one

Prescription Medications

Medications MUST be in the original medication prescription bottle.

The medication prescription bottle MUST match what the camper actually takes AND match the camper’s name that is on the Medical Release Form.

Examples:

(1) Atenol 50mg one tab daily But, the camper states: I only take ½ of that pill.

(2) Synthroid 137mcg one at bedtime But, the camper states: I take it in the morning not at bedtime.

The camper must be given medication per instructions on the prescription bottle.

All medications must be in date and not expired. Including Epinephrine Pens, Inhalers, Nebulizer Medications & Insulin.

Medication #1 : Name*

Medication #1: Dosage*

Medication #1: Time Given*

Medication #1: Special Instructions

Medication #2 : Name

Medication #2: Dosage

Medication #2: Time Given

Medication #2: Special Instructions

Medication #3 : Name

Medication #3: Dosage

Medication #3: Time Given

Medication #3: Special Instructions

Medication #4 : Name

Medication #4: Dosage

Medication #4: Time Given

Medication #4: Special Instructions

Medication #5 : Name

Medication #5: Dosage

Medication #5: Time Given

Medication #5: Special Instructions

Medication #6 : Name

Medication #6: Dosage

Medication #6: Time Given

Medication #6: Special Instructions

Additional Medications - If you have additional prescription medications, please list Name, Dosage, Time, and Special Instructions here.

Over-The-Counter Medications List

Campers should not bring any over-the-counter medications such as: Benadryl, Tylenol, Zyrtec, unless a specific brand has been prescribed by a doctor OR vitamins. We will administer over-the-counter-medication to your student from our medication cabinet as you have listed on the medication form.

O-T-C Medication #1 : Name*

O-T-C Medication #1: Dosage*

O-T-C Medication #1: Time Given*

O-T-C Medication #1: Special Instructions

O-T-C Medication #2 : Name

O-T-C Medication #2: Dosage

O-T-C Medication #2: Time Given

O-T-C Medication #2: Special Instructions

O-T-C Medication #3 : Name

O-T-C Medication #3: Dosage

O-T-C Medication #3: Time Given

O-T-C Medication #3: Special Instructions

O-T-C Medication #4 : Name

O-T-C Medication #4: Dosage

O-T-C Medication #4: Time Given

O-T-C Medication #4: Special Instructions

O-T-C Medication #5 : Name

O-T-C Medication #5: Dosage

O-T-C Medication #5: Time Given

O-T-C Medication #5: Special Instructions

O-T-C Medication #6 : Name

O-T-C Medication #6: Dosage

O-T-C Medication #6: Time Given

O-T-C Medication #6: Special Instructions

Additional O-T-C Medications - If you have additional O-T-C medications, please list Name, Dosage, Time, and Special Instructions here.

DIETARY INFORMATION

Alto Frio is happy to provide dietary accommodations to anyone for whom it is medically necessary.

PLEASE CHECK THE APPROPRIATE BOX BELOW (dietary)*

I DO NOT require special dietary considerations. I DO require special dietary considerations because of a medical condition.

Please list special dietary considerations for medical conditions below.*

None Diabetic Gluten Free Lactose Intolerant Peanut Allergy Shellfish Allergy Tree Nut Allergy Vegetarian

Other:

CONSENT

In consideration for your agreeing to accept the above named individual as a camper, I hereby give my authority and consent to medical and surgical treatment as may be needed in the judgment of the treating physician chosen by the Alto Frio Administrator, the sponsoring church, or their representatives. I understand the twenty four (24) hour first aid station is available. I further understand that limited secondary accident and illness coverage is provided.

I also understand that all medications must be in original prescription bottles, no loose pills will be accepted and that the name on the prescription bottle must match the name on this form and all medications must be listed on this form. I further understand that should I send medications that do not meet these guidelines, that these medications WILL NOT be administered.

I understand that parts of the Alto Frio challenge course program may be physically/emotionally demanding. I affirm that my health is good, and that I am not under a physician’s care for any undisclosed condition that bears upon my fitness to participate in challenge course activities. I understand that the level of participation in these activities is at all times completely voluntary and up to the individual’s choice. Also, I recognize the inherent risk of injury or disability in challenge course activities and understand that each participant must assume the risk of injury that could result from any of the activities. I release Alto Frio Baptist Encampment and it’s staff members, principals, and board from all liability for any injury to me from participation in Alto Frio challenge course activities.

I expressly understand and acknowledge that during the course of the camp photographs or video footage of my child may be taken and I hereby give permission for such photographs or videos to be used on the camp website and/or promotional materials for the camp.

I expressly give permission for Alto Frio Baptist Encampment to share this information with the Youth Minister, Pastor, or Youth Leader listed above to be used during travel to and from Alto Frio Baptist Encampment.

Please initial (Parent/Guardian)*

I, as parent or guardian of the camper specified above, authorize the Alto Frio Camp Medical Professional to distribute any prescribed and/or over-the-counter medications to my child that meet the above mentioned guidelines.

Please initial (Adult Camper)*

I, the camper specified above, authorize the Alto Frio Camp Medical Professional to distribute any prescribed and/or over-the-counter medications that meet the above mentioned guidelines.

Parent/Guardian Signature*

[clear]

Camper Signature*

[clear]

Printed Signature Name*

First Name

Last Name

Date*