Byrd - Kaylee - 03 09 2014 - 21 32 17

COVER PAGE
Kaylee Byrd
Age: 13 Session 3
173932 RID: _________
Congratulations! You have successfully completed your campers online medical information. Once you have completed the Medical Documentation Checklist, please collate the documentation in the order listed below and fax, email or mail to Camp Ozark. This sheet will serve as the cover page, please place on top before sending to Camp Ozark.
CHECKLIST
ALL CAMPERS
BARCODES (office use)
COPY of INSURANCE COPY of SHOT RECORDS COMPLETED PHYSICAL

(Doctor Signature Required)
CHECKLIST
CAMPERS WITH MEDICATIONS
BARCODES (office use)
MEDICATION FORM (OPTION 1)

(Send Meds to Camp)
MEDICATION FORM (OPTION 2)

(Send Prescriptions to Camp)
Fax 713-800-7493
Mail Camp Ozark 155 Camp Ozark Drive Mount Ida, AR 71957
Health Card due
Email docs@campozark.com
DEADLINE
May 1st, 2014
Shot Records and Insurance documents due Medication and Pharmacy forms due (If Applicable)
Kaylee Byrd
2014 Camper Health Card
155 Camp Ozark Dr. Mt. Ida, AR 71957 (870) 867-4131 Fax (713) 800-7493
DOB: 12/11/2000 Age: 13 Girl Session(s): 3
Camp Ozark Office Use Only Session _____ Cabin # _____ 3 Temp _______ HV _________ Comments _________________ 173932 RID _______________________
2014
Emergency Contacts
Contact Name
Mother Kristy Byrd Father Tony Byrd Grandmother Rhonda Fleming
THIS SIDE TO BE CHECKED WITH PHYSICIAN AT TIME OF EXAMINATION Address

2022 Lunenburg Dr 2022 Lunenburg Dr Allen Allen
Phone 1
TX 75013 214-356-3819 TX 75013 214-356-3919 501-276-6211
Phone 2
214-356-3919 214-356-3819 2142766211
Insurance
Hospitalization Company
Blue Cross Blue Shield
I do not have health insurance] Policy ID #

ISD840778009
Group #
085000
Member ID #
PTROA
Phone
866-355-5999
Prescription Company
Policy ID #

Rx PCN # Mercy Health Center
Rx Group #
Rx Bin #
Preferred Hot Springs healthcare provider:
National Park Medical Center
Health History
Seizures Asthma Heart Condition Past Hospitalization Recurrent/Chronic Illness Diabetes ADD/ADHD Staph Infection Has Ear Tubes Head Injury/Concussion Sleepwalking Bedwetting Treated for Mental/Emotional/Behavioral Difficulties or Eating Disorder Past Surgery Significant Life Event Affecting Campers Life Seen Professional for Mental/Emotional Concerns Traveled Outside U.S. in Past 9 Months Country ____________________ Date _____________________ Other ____________________________________ Comments:
Allergies
Type
Food Drug Environmental

Name
Immunization History

(Current immunizations required for camp attendance. No Exceptions.)

Please notify the camp if your camper has been exposed to any communicable disease during the THREE WEEKS PRIOR TO CAMP ATTENDANCE. (Chicken Pox, Measles, Mumps, Flu, etc.)
Tetanus Booster (TDaP) 05/01/2010 Date _____________ All Other Immunizations Current
PARENTS AUTHORIZATION: I hereby give my permission to the medical personnel selected by Camp Ozark to provide routine healthcare, to administer medications, both over the counter and prescription, to order X-rays, and routine tests, to hospitalize, secure proper treatment for and to order injection, anesthesia or sugery for my child named on this form. In addition, I authorize Camp Ozark or its designees to provide or arrange necessary related transportation for my child. In addition, I authorize the release of all records, X-rays, notes and any other medical information to Camp Ozark or its designees. If my health insurance is not accepted by local providers, for any reason, I will be fully responsible for payment. I agree the electronic signature affixed to this document is the legally binding equivalent of my handwritten signature.1
Electronically Signed By
1 The
Kristy Byrd
Date
03/09/2014
electronic signature is unique to both the document and the signer and binds both of them together. Any changes made to the document after it has been signed invalidates the electronic signature, thereby protecting against signature forgery and information tampering in accordance with E-Sign Act of 2000.
HEALTH SCREENING
Camp Ozark Office Use Only 173932 RID ___________________
2014
MUST BE FILLED OUT BY LICENSED PHYSICIAN This examination should be performed within twelve (12) months of arrival at Camp Ozark. Examination for any purposes within this period is acceptable; however this Camp Ozark health form must be completed by a physician. School or athletic forms are not acceptable. Examination is for determining fitness to engage in strenuous activities. CODE: Satisfactory Not Satisfactory (Explain) Not Examined Height Weight Eyes Throat Glasses Dental Ears Heart Nose Lungs Skin Hernia (Females) Has this person menstruated? Menstrual history normal? Special Health Considerations Swimming/Diving Strenuous Activity Other Blood Pressure Posture (Spine) Abdomen Allergy General Appraisal Yes No Extremities Hemoglobin (Optional) Urinalysis (Optional)
If not, has she been told?
Recommendations & Restrictions while at Camp Ozark:

Dietary
Please notify Camp Ozark in writing, in advance, of any major dietary restrictions, which require special menu adjustments. Camp Ozark is unable to guarantee that all requests can be met. Each case is considered on an individual basis.
Please list any medications camper will be taking at camp:
Prescription Name 1. 2. 3.
Dosage
Frequency
Reason for Taking
Note: If you have listed any medications in the above space, you must refer to and complete the medication portion of the medical section of your campers online registration.
Essential Functions of a Camp Ozark Camper

A successful camper must be able to, above all, function independently (does not require one on one supervision) in a remote, rustic (with no air conditioning) atmosphere for a one-week to four-week time period while living cooperatively with others. The Camp Ozark program is very active and physically challenging for campers. Daily activities include one hour every day of rigorous (often involving physical contact) team competition, and at least three hours of group activities, some of which require physical stamina and most of which are conducted outdoors. All swimming is in a spring fed lake with limited visibility. If a camper has a seizure disorder, he/she must wear a life jacket. If a chronic medical condition exists, the campers must be capable of self-management. A camper must be capable of effective interaction in a group based or community living environment. If the camper appears to have any serious behavioral issues or special circumstances involving physical, psychological, social, or emotional handicaps, the Camp Director should be notified of this NOW because children who do not have the promise of living independently and cooperatively with other children or safely within our environment cannot be accepted.
I have reviewed the Essential Functions of a Camp Ozark Camper and have examined this person herein described and have reviewed his/her health history. It is my opinion that he/she is physically able to engage in camp activities except as noted above.
Examining Physician Signature Print Name of Physician
Date Email
Phone

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COVER PAGE

173932 RID: _________

BARCODES (office use)

COPY of INSURANCE COPY of SHOT RECORDS COMPLETED PHYSICAL

CAMPERS WITH MEDICATIONS

BARCODES (office use)

MEDICATION FORM (OPTION 1)

MEDICATION FORM (OPTION 2)

May 1st, 2014

DOB: 12/11/2000 Age: 13 Girl Session(s): 3

THIS SIDE TO BE CHECKED WITH PHYSICIAN AT TIME OF EXAMINATION Address

I do not have health insurance] Policy ID #

Rx PCN # Mercy Health Center

Preferred Hot Springs healthcare provider:

National Park Medical Center

(Current immunizations required for camp attendance. No Exceptions.)

Camp Ozark Office Use Only 173932 RID ___________________

If not, has she been told?

Recommendations & Restrictions while at Camp Ozark:

Please list any medications camper will be taking at camp:

Reason for Taking

Essential Functions of a Camp Ozark Camper

Examining Physician Signature Print Name of Physician

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