Health Form

2019 SHINE SUMMER DAY CAMP CHILD HEALTH RECORD

Child's Name*

Date of Birth*

Sex*

Boy
Girl

Please upload a school type photo of your child*

* Recommended dimensions for images is 300 x 338 pixels

Health Insurance*

Identifying Numbers*

Child’s Physician Name*

Physician’s Phone#

Address*

Street Address City State ZIP Code

1) Health History

A) List any allergies that your child has (medication, foods, etc.):

B) List any operations or serious injuries:

2) Medications Needed or Used (including psychiatric):

Include up to 3 medications needed or used

Medication	Frequency	Dosage	Currently Being Given? Yes / No

* If Daycamp staff will be administering medicine to your child, please complete the Medication Permission and Instructions sheet. Any medication brought to the Day Camp for the Staff to administer must have the pharmaceutical label affixed to it.

3) Restrictions

A) Should child's activity be restricted because of any physical defect or illness?*

No
Yes

If yes, explain degree of restriction:

B) Does child currently have any infectious diseases?*

No
Yes

If yes, please explain.

C) SHINE Daycamp staff may apply, or assist my child in applying, topical nonprescription medications, including sunscreen and insect repellent:*

Yes
No

4) Immunizations

My child’s immunizations are up to date:*

Yes
No*

* If no, answer the following:

A) The State of MI vaccination exempt sheet is on file with my child’s school

Yes
No

B) Please sign: My child is in good health, and I assume responsibility for my child’s state of health while at Shine Daycamp.*

5) Swimming Ability

My child is a...*

strong swimmer
weak swimmer
not a swimmer

6) Conditions and Symptoms

Check and describe any that apply

Allergies (Hay Fever / Asthma)
Allergies (Food)
Diabetic / Hypoglycemia
Headaches
Stomach Aches
Other

Allergies (Hay Fever / Asthma)

Noticeable symptoms?	Medications needed. Dosage and times.	What causes or precedes this condition?	How do you (parent) handle this situation?

Allergies (Food)

Noticeable symptoms?	Medications needed. Dosage and times.	What causes or precedes this condition?	How do you (parent) handle this situation?

Diabetic / Hypoglycemia

Noticeable symptoms?	Medications needed. Dosage and times.	What causes or precedes this condition?	How do you (parent) handle this situation?

Headaches

Noticeable symptoms?	Medications needed. Dosage and times.	What causes or precedes this condition?	How do you (parent) handle this situation?

Stomach Aches

Noticeable symptoms?	Medications needed. Dosage and times.	What causes or precedes this condition?	How do you (parent) handle this situation?

Other

Noticeable symptoms?	Medications needed. Dosage and times.	What causes or precedes this condition?	How do you (parent) handle this situation?

7) Special Needs

Please list learning disabilities, developmental delays, emotional difficulties, physical handicaps, etc:

Some children have current or special needs which require skills beyond our expertise and licensing. If your child has a medical, diet, physical disability, behavior disorder, learning or developmental disability, please contact us to see whether SHINE daycamp is a good match for your child.

Signature of parent or guardian

Digital Signature Acknowledgement*

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

menu