University of rhode island w

UNIVERSITY OF RHODE ISLAND W. ALTON JONES CAMPUS
TEEN EXPEDITIONS HEALTH HISTORY FORM
SEND IN BY JUNE 15

Parent/Guardian: Please complete both sides of this form and send it to camp by June 15 with the Medical
Exam Form. If your child requires special treatments, injections, is immune compromised, or has mobility
limitations (e.g. crutches or wheelchair), no spleen, food allergies, or dietary restrictions, you must contact the
nurse by phone at least two weeks before the program (401-397-3304 ext. 6043).
Dates of Session(s)_________________________________________________________________________
Child's Name______________________________________________________ Age______ Weight________
Address___________________________________________________________ R Boy R Girl
__________________________________________________________________ Birth Date_______________
Mother's Name_____________________________________________________________________________
Telephone home:(_____)_________________work:(_____)________________cell:(_____)_______________
Father's Name_____________________________________________________________________________
Telephone home:(_____)_________________work:(_____)________________cell:(_____)_______________
Name of another person to be contacted in case of emergency if you cannot be
reached:_______________________________________________ Relation to child:_____________________
Telephone home:(_____)_________________work:(_____)________________cell:(_____)_______________
Parent/Guardian's Health Insurance Company_____________________________________________________
Policy
Number___________________________________________________________
NOTES TO PARENTS:
1. URI provides insurance for up to $3,500.00 per injury. The parent/guardian is responsible for costs beyond this limit.
2. If your child has had or has been exposed to a contagious disease or gets a serious cut, bruise, sprain, break, other injury
or skin rash during the week prior to coming to Alton Jones, please contact our nurse by phone.
3. All medications will be kept by an Expedition Leader assigned to your child’s group except Inhalers and Bee Sting
Kits/Epi-pens which must be carried by participants at all times. (Please include a fanny pack for teens who must
carry these emergency medicines).

4. All medications must be in original container and properly labeled, correlated with written instructions and placed in a
ziploc bag.
5. Prescription Medication: If your child is bringing medication prescribed by a physician, the medication must be in the
original container with the doctor’s orders on the container. Medications will be dispensed as specified on the container
unless a physician’s note is attached indicating a change in dosage. The medication will be dispensed under the
supervision of an R.N. or other authorized staff member.
6. An information sheet on ticks and tick-borne illnesses is enclosed. Please read it carefully.
7. If it is OK for staff to administer Tylenol, Benadryl, or ibuprofen if needed, parents please initial here:______________
If your child is bringing prescription medication please complete the following:
MEDICAL BACKGROUND

If YES is checked, give approximate dates, method of treatment, and or restrictions. If your child is under the care of a Social
Worker, Psychologist, Behavioral Therapist etc., please fill in specific information concerning your child's needs.
Bleeding Disorders
RYes RNo_______________________________________________________________ RYes RNo_______________________________________________________________ RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ Vegetarian RYes RNo ______________________________________________________________
Traveled out of U.S. in last 3 mo. RYes RNo Country(s)____________________________Dates_____________________
Does your child have any allergic reactions to: (Please note reaction eg. Ingestion vs. Touch)
Bee Stings
RYes RNo ___________________________________________Epi-Pen RYes RNo RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ RYes RNo ______________________________________________________________ Has you child been exposed to any contagious diseases 4 weeks prior to visiting Alton Jones must call RN. Is child under special treatment? RYes RNo ______________________________________________________________ RYes RNo _______________________________________A doctor’s note is required.
RYes RNo Date:_________________________________________________________ RYes RNo ______________________________________________________________
Bringing over the counter meds? RYes RNo Please complete the following:

Permission to secure treatment: I give permission to have my child treated by the W. Alton Jones Campus nurse,
authorized staff, or a physician in case of severe illness or emergency in which I cannot be reached. In the event that an
illness or injury should arise in which a doctor's diagnosis is required, I authorize the campus management to dismiss my
child early, in which case I will assume responsibility for arranging transportation. I hereby assume responsibility for all
medical expenses for my child not covered by the University of Rhode Island accident insurance policy. (Please note that
some hospital emergency rooms require notarization for permission to treat a minor. To promote optimal treatment
security for your child, please have this form notarized.)
___________________________________________________
___________________________________________________ UNIVERSITY OF RHODE ISLAND W. ALTON JONES CAMPUS
ENVIRONMENTAL EDUCATION CENTER
MEDICAL EXAM FORM
SEND IN BY JUNE 15

To comply with state regulations and American Camping Association standards, you must provide evidence
that your child has had a health examination within the 24 months prior to participation in a Teen
Expedition (12 months recommended) by a licensed physician, a certified nurse practitioner, or other medical
personnel licensed by the state to conduct health examinations.
Please choose ONE of the options below and present to the nurse at check-in:
1. CALL your physician's office and have them send YOU a copy of your child's last health examination or a form indicating that an examination had been conducted and indicating any special treatments or considerations about your child’s participation in camp activities. Be sure to verify that the date of the examination was within 24 months of attendance (12 months recommended). Attach the copy to this blank form. 2. Have your physician fill out, sign, and date the form below. 3. Have your physician's secretary fill out, stamp, and date the form below with an official stamp. MEDICAL EXAMINATION
Name of participant_______________________________________________Age________ Does this child have any physical condition requiring restriction(s) on participation in the camp program? If yes, attach information on restrictions. Does this child have any current or on-going treatment and/or medications? I have examined and questioned this child on_________________________________. I understand the nature of the program and activities involved, and I believe he/she is capable of participating in Teen Expedition activities offered by the W. Alton Jones Campus. (Exceptions attached.) ____________________________________ PARENT/GUARDIAN AGREEMENT
Teen Expeditions
SEND IN BY JUNE 15

In order that the W. Alton Jones campus staff may provide each Teen Expeditions participant maximum opportunity for
personal growth, I understand that in signing this agreement I certify that my child is healthy and free of problems that
could be detrimental to his/her safety or that of other campers while participating in Teen Expeditions. I have read and I
understand the brochure description, the enclosed letter, the packing information, and the trip descriptions in the brochure
and online at www.altonjonescamp.com.
In the event that my child's behavior is felt to be unsafe or unmanageable, or if an illness or injury should arise in which a
doctor's diagnosis is required, I authorize the program management to dismiss my child early, in which case I will assume
responsibility for transporting my child from the W. Alton Jones Campus or another location convenient to the expedition
route (Maine, for example), at a time specified by the program management. If I am not available, I authorize the people
listed (see below) to pick up my child.
I grant permission for the participant named on this form to participate in off-campus trips both in Rhode Island and out of
state by camp-authorized transportation (primarily 12-passengar extended vans). I grant this same participant permission
to participate in all planned activities dictated by the program my child is attending including, but not limited to
swimming, canoeing, kayaking, rockclimbing, rappelling, bicycling, use of high and low-ropes challenge courses, rafting,
hiking, or backpacking. I understand that the Teen Expeditions program activities by nature will expose my child to
potential dangers both from known risks and from unanticipated risks. I further understand that at times my child may be
away from the safety net of civilization, more than an hour from a local hospital, and that the potential exists for my child
to be exposed to severe and dangerous weather, wild animals, ticks, biting and stinging insects, people who are not
program participants, loss or separation from the group, forest fires, and falls due to steep or uneven terrain, among other
things. I realize that, while at least one teen expedition leader on each trip will carry a cellular phone, some of the areas
that my child may visit are out of the range of cellular towers. I recognize that the W. Alton Jones Camp reserves the
right to change plans if circumstances dictate. I also understand that if the health or safety of other campers or staff or
suspicion of theft indicates the need, campers may be required to inventory their belongings in the presence of staff
members. The W. Alton Jones Campus is not responsible for lost or stolen items.
I authorize the University of Rhode Island to take, have, and use photographs, computer images, and recordings of the
person named on this form as may be needed for its records or for public relations purposes. It is my understanding that
the University of Rhode Island provides limited accident insurance coverage for all Teen Expeditions participants up to
$3500.00 maximum per injury. I understand that in signing this agreement, I hereby assume responsibility for all medical
expenses for my son/daughter not covered by the University of Rhode Island accident insurance policy.
I understand that a photo driver's license (or equivalent photo ID) is required to pick up my child. In an
emergency when I cannot be reached, or if I (the person signing this form) cannot pick up my child at the end of
camp, I authorize the following people to sign out my child upon presentation of a photo ID.

Camper's Name (please print) __________________________________________________

Spouses and ex-spouses must be listed if you would like them to be able to pick up your child.
Name_____________________________________________________ Relation to Child_______________________
Telephone home:(______)_________________work:(______)_________________ cell:(______)_________________
Name_____________________________________________________ Relation to Child_______________________
Telephone home:(______)_________________work:(______)_________________ cell:(______)_________________
Parent Guardian Signature:________________________________________________________Date________________
Telephone home:(______)_________________work:(______)_________________ cell:(______)_________________
Print Name: _________________________________________________________________

Check Out:
Signed ________________________________________________________________Date_________________
SOME THOUGHTS ON HOMESICKNESS

Often thought to be restricted to the very young, homesickness among Teen Expeditions participants is fairly common.
Going on an expedition can be an intimidating experience for teenagers. Homesickness is either a mild or severe form
of anxiety, which can sometimes occur until a person becomes adjusted to new surroundings and social situations. It is a
very real and natural emotion that can occur in anyone, child, teen, or adult, when they leave familiar people and places
for a new adventure. It is important that parents and teens are prepared for it before check-in day.

How can we help teens avoid homesickness?

Before the Expedition Begins:
First timers will benefit from having gone on other less threatening experiences away from home such as overnights
with grandparents and friends or attending a day camp. Involving your teen in as many decisions as possible about their
expedition beforehand can also help. Packing can be a sensitive time since some teens will become overly self-
conscious if they feel they don’t have the right clothes and appropriate gear. Packing a special memento can help to
provide a treasured reminder of home.
Talk to your teen about the exciting experience they will have exploring new activities and meeting other teens.
Families should speak openly about the possibility of homesickness. Discuss what the expedition will be like well
before your teen leaves home and discuss any concerns. Don’t state up front that you will “rescue” them if they don’t
like the expedition. Most homesickness fades away as a teen becomes comfortable with new people and surroundings.
For some teens overcoming homesickness can be a developmental milestone.
One suggestion is to send an encouraging letter that will be waiting for them when they arrive at camp. Camp Fire Boys
and Girls conducted a study which concluded that a written message letting kids know they’re important, loved, and
appreciated can make a lasting impact on their lives. Letters should not include any bad news or stories about what the
family is doing that may leave them feeling left out. Also, don't dwell on how much you, the pet, or siblings miss them.
It’s not that we want teens to forget about home, we just don’t want them to dwell on home to the exclusion of their
current experience.
On Check-in Day:
Check-in day can be exciting yet difficult for parents and teens. It is normal to be nervous. On check-in day try not to
dwell on the subject of homesickness prior to arrival at camp. Direct your teen towards thinking of the positive things
they will be involved in during their expedition. Rainy day arrivals can be the most difficult since the surroundings will
not feel as warm and friendly as they do on a sunny day. Focus on the positive. After checking in, help them move their
gear to the expedition base camp and assist them in meeting their leaders and a few other trip-mates. Try not to linger
too long. Once they are settled, it is time to say goodbye. Give words of encouragement, say your good-byes, and leave
them to their experience. Soon they will be engaged in exciting activities.
During the Expedition:
Once the camp program is underway, we try to keep campers so busy that they will have little time to reflect on home.
Most child psychologists agree that telephone calls to or from home make homesickness much worse or stimulate it in
children who are not experiencing homesickness. Because of this, we do not allow expedition participants to call home
(except in cases of severe or persistent homesickness). Our approach is to get them involved and engaged as much as
possible in what is happening around them. Feel free to call and speak with the Teen Expedition Coordinator at any
time if you would like reassurance that your child is OK. They may have to check in with the group and get back to you
later but they will be honest with you about how your child is doing.
Although there are rare times when sending a someone home will be the right choice, teens overcome homesickness and
adjust within a day or two in the vast majority of cases. At Teen Expeditions, children learn to problem-solve, make
social adjustments to new and different people, learn responsibility, and gain new skills to increase self-esteem. The
goal is to provide a safe, fun, and educational experience for teenagers, while assisting their positive growth and
development. It would be unfortunate to have them miss out on developing these life skills because of an early bout
with homesickness. With support and encouragement, most teens adjust very quickly to their new surroundings.
TICKS AND YOUR TEEN
Blacklegged ticks, also known as deer ticks (Ixodes scapularis), which can carry Lyme Disease as well as the less common Human Granulocytotropic Anaplasmosis (HGA) and Babesiosis, are prevalent in Rhode Island. Disease carrying ticks have been found in 43 states and are common in many parts of the Northeast. Caution is appropriate for anyone spending time in the outdoors. Here are answers to some commonly asked questions about ticks. What is the likelihood of my child getting a tick-borne disease at Alton Jones? It is unlikely that your child will get
a tick-borne disease from attending a program at the URI W. Alton Jones Campus. We work diligently to minimize risks
and provide maximum protection for each child who attends our programs. We feel it is important to keep parents
informed so that if a child displays symptoms, a prompt diagnosis can be made and proper treatment can be given.
What measures are taken to prevent tick bites? While the risk of getting a tick-borne illness at W. Alton Jones is
low, we take a proactive approach. We teach children to be aware of ticks and methods of tick-bite prevention. We talk
to them about ticks at their first orientation meeting. We teach them how to check themselves for ticks and frequently
remind them to do so. We work to keep our trails trimmed back and we make every effort to avoid high-tick areas.
What if a tick bites my child? In the event that an embedded tick is found on a child, a trained staff member will
promptly remove the tick. It is possible for an infected tick to be embedded for up to 48 hours before transmitting a
disease. Prompt tick removal will reduce the likelihood of disease transmission. We call the parents of any child who is
bitten by a tick so that they can help monitor the child for symptoms once they are home.
What are the symptoms of tick-borne diseases? We encourage all parents and children to become familiar with the
symptoms since a tick bite can go undetected. If any symptoms occur, contact your doctor and tell them that your child
may have been exposed to ticks. Many symptoms are flu-like while tick-borne diseases are most likely to occur outside
of the normal flu season.
• Lyme Disease: Early symptoms generally appear within a week and include an expanding (often but not always
bulls-eye shaped) skin rash that can be, but is not always, near the bite site. The rash occurs in 60% to 80% of all cases, appears 3 days to 1 month after the bite, and confirms a diagnosis of Lyme Disease. Also watch for chills, fever, headache, stiff neck, fatigue, swollen lymph nodes, dizziness and aching joints and muscles. Another possible symptom is swelling and pain in the joints, especially the knees. These symptoms may not seem serious enough to warrant initial concern. Lyme Disease is the most common tick-borne disease and is treatable with antibiotics.
• Human Granulocytotropic Anaplasmosis (HGA): Symptoms include fever, headache, malaise, chills, sweating,
muscle aches, nausea and vomiting. Symptoms may be severe and it is sometimes initially misdiagnosed as meningitis. This disease is rare but has been increasing in recent years. It is treatable with tetracycline derivative drugs (used with caution since some drugs will permanently stain children’s teeth).
• Babeseosis: Symptoms are generally mild or go unnoticed and may require no treatment but can be severe in rare
cases. Symptoms occur within 1 to 4 weeks and include a gradual onset of malaise, loss of appetite, and fatigue followed within a week or so by fever, drenching sweats, shaking chills, nausea, vomiting, headache, muscle pain, weakness, and depression. This disease is extremely rare particularly in children, however people with impaired immune systems or those who have had their spleen removed are at risk of severe and possibly fatal reactions. What can parents do to help prevent tick bites? Insect repellents can be sprayed on clothing or skin to help prevent
tick bites. Be sure that the label says it is affective against ticks and that it contains 30% or less of the chemical DEET
since that is the maximum concentration currently recommended for children. Permethrin is highly effective against
ticks but can only be applied to clothing. Light colored clothing helps in locating ticks. Keeping ticks off children and
removing them before they bite or transmit a disease are the keys to prevention.
Assist us in tick bite prevention by helping your son or daughter thoroughly check themselves for ticks as soon as they return home. Remove any embedded ticks with tweezers. Launder dirty clothing promptly and dry at high temperatures. Know and watch for symptoms of tick-borne diseases. Please call 401-397-3304 ext. 6043 if you have further questions or if your child contracts a tick-borne disease and you believe it was from attending a program at Alton Jones (we try to keep track of cases). We welcome your comments.

Source: http://www.uri.edu/ajc/eec/pdf/Web%20Text-Online%20Forms%20Teen%20Exp.pdf