Microsoft word - ac health 2013.doc

Children's Museum of the Arts 103 Charlton Street, New York NY 10014 PAGE 1 TO BE COMPLETED BY PARENT/GUARDIAN BEFORE PRESENTATION TO PHYSICIAN If Parent/Guardians are not available in an emergency, notify: My child has my permission to walk to/from the camp site and/or ferry by him/herself. IMPORTANT: Please notify the Program Manager if this child has been exposed to any communicable diseases three weeks prior to today's date. Please state type of exposure: HEALTH HISTO RY (Check, giving approximate dates) Ear Infections Rheumatic Fever Convulsion CURRENT CO NDITIO NS Medication(s) Taken: Conditions which modify activity (seizures, amnesia, heart conditions, etc.) Does family have medical insurance? q Yes q No Insurance Company: Does family have Hospitalization Policy? PHO TO / TRIP RELEASE & CO NSENT FO R EM ERG ENCY M EDICAL TREATM ENT & M EDICATIO N • I give permission for my child’s picture to be used by Children’s Museum of the Arts in promotional materials without compensation (e.g. calendar, brochure, video, website, etc.). • I hereby give permission for my child to participate in all program activities and day trips as part of the Children’s Museum of the Arts Art Colony program unless noted otherwise on this form. • I hereby give authority to Children’s Museum of the Arts camp staff to administer over-the-counter medication in the proper dosage to my child if needed (e.g.: Tylenol, Motrin, Benadryl, etc.) and to administer other medication as prescribed by a physician without my further consent. In case of emergency, I give authority to Children’s Museum of the Arts staff to obtain emergency treatment for my child with the understanding that the family will be notified as soon as possible, and I hereby authorize the doctor or the hospital to which my child may be brought (and whomever they may designate as their assistants) to perform any emergency procedure or operation, to give treatment, and to administer an anesthetic to my child during his/her stay at Children’s Museum of the Arts Art Colony camp. By my signature, I hereby certify that all above information is approved and correct unless otherwise indicated. PHYSICAL EXAMINATION TO BE FILLED OUT BY PHYSICIAN The purpose of this health record is to provide the staff with pertinent information that will help to serve the needs of this child in The Children’s Museum of the Arts programs. Attaching a printout of a recent physical examination is also acceptable. CHILD'S NAME (Last, First) _________________________________________________________________ IMMUNIZATION HISTORY: This is a record of dates of basic immunization and most recent booster doses. According to New York State Law, a second MMR immunization must be administered to every child born before 1985. DPT or DT or TD MEDICAL EXAMINATION: To Be Filled Out by Licensed Physician CODE: S = Satisfactory X = Not Satisfactory (explain) O = Not Examined Describe Abnormal Findings and/or Handicapping Conditions: Has child ever received products containing horse serum?: RECOMMENDATIONS AND RESTRICTIONS WHILE IN THE PROGRAM: Special Diet: Will special medication need to be administered to child at camp? If so, explain: I have exam ined the person herein described, reviewed his/her health history and it is my opinion that he/she is physically able to engage in Children’s Museum of the Arts Art Colony camp activities, except as noted above.

Source: http://cmany.org/wp-content/uploads/2013/10/AC-Health-2013.pdf