Iowa Lakes
University of Okoboji
Reggie Schive
Summer Jazz Camp

Camper Health and
Medical Authorization Form

 

Camper Health History and Authorization Form

Name of Camper_______________________________________________________________

Date of Birth_________________Sex __Male  ___Female       Grade Completed___________

Custodial Parent/Guardian_______________________________________________________

Address, City, State, Zip_________________________________________________________

Home Phone________________Work Phone _________________  Cell Phone____________

Employer______________________________________________________________________

Employer Address _____________________________________________________________

Other Legal Parent/Guardian____________________________________________________

Address, City, State Zip__________________________________________________________

Home Phone________________Work Phone___________________ Cell Phone ___________

Employer_____________________________________________________________________

Employer Address ______________________________________________________________

Emergency Contact (someone other than parent/guardian who is NOT listed above.  In the event of an
emergency, we will make every effort to contact the Parent/Guardian first. 
However, in the event the parent/guardian cannot be reached, we will contact the person you have listed.)

Name ______________________________________Phone Number______________________

Relationship to camper__________________________________________________________

Is Camper covered by Health Insurance?     __ Yes        __No

If yes, Please attach a copy of the front and back of the card to this form!

If yes, do you have   _____Title XIX      ___Medicaid       ____Medipass        

Is this coverage through:    __ Group/Father Employer           ___Group/Mother Employer

                                            __ Individual Policy                     ___Other________________

Policy Number____________________________   Group Number______________________

Insurance Company____________________________________________________________

Address_______________________________________________________________________

Policy Owner__________________________________________________________________

SS# of Policy Holder____________________________SS# of Camper___________________

Birthdate of Policy Holder_______________________________________________________

 Diseases or Health Concerns:

___Chicken Pox           ___Ear Infections                     ___Migraines

___Measles                  ___Rheumatic Fever                ___Nosebleeds

___Mumps                   ___Diabetes                             ___Braces

___Asthma                   ___Behavior                            ___Heart

___Convulsions             ___Seizures/convulsions            ___Fainting

___Sleep Walking         ___Hearing Impaired                ___Eczema

___Bed Wetting            ___Vision Impaired                  ___Hives

___Back Pain               ___Chronic Illness                    ___ADHD                           

___Stomach upsets       ___High Blood Pressure            ___Cramps

___Homesickness         ___Cold/Pneumonia                  ___Other

Allergies (Please List and specify) _______________________________________________

Medication and drug allergies. Please list and specify _________________________________

__________________________________________________________________________

Doctor’s Name ________________________________ Phone________________________

Address_________________________________________________________________

Are Camper’s immunizations current?   __Yes      ___No

___DPT Series                ___Booster               ___Tetanus Booster

___Polio OPV(Sabin)     ___Booster               ___Tuberculin Test

___MMR                        ___Other (please list)___________________________ 

Please list any dietary restrictions or food allergies: ______________________________

_______________________________________________________________________

Will your child have difficulties participating in any activities? ___ yes ___ no   If yes, please explain: ___________________________________________________________

Do you have disability-related accommodation needs?  ___ yes   ___ no  
If yes, please call Linda Helmers at 1-800-242-5106 ext. 364 for specific requests.

To Parents/Guardians:  The law requires that before medical services can be administered to a person less than 21 years of age; permission of the parent/guardian must be secured.  In the event of serious illness or accident, every effort will be made to contact parent(s)/guardian(s).  However, in the event that delay in medical or surgical treatment might be detrimental to the health of the student, your authorization for consultation and treatment by physicians is requested.

 This form authorizes the Director of the Jazz Camp or any staff member to carry out the following action regarding the medical care of ______________________________________.       

 This authorization shall extend to any time when said child is enrolled in Jazz Camp. 

1.  I authorized Jazz Camp to use local and/or out-of-town hospitals and clinics for the treatment of an illness or an accident.  I further authorize Jazz Camp to select a qualified licensed physician or surgeon for necessary emergency treatment when required.

 2.  I authorize the Jazz Camp Director and staff members to render such information as required by hospital admission rules and to sign, as a competent adult, forms permitting examination and possible treatment.

 I understand that physician(s) and hospital(s) are reluctant and sometimes unwilling to examine and treat patients without such authorized signature(s.)  Jazz Camp will permit only routine and emergency procedures, which include preventive and corrective treatment.  However, I understand that major or prolonged treatment will be consented to only with my specific permission, except when such permission is impossible to obtain within the limitations of time or other emergency conditions.