Upward Bound Camp for Persons with Special Needs, Inc.

Serving by providing celebration of life with purpose since 1978 American Camping Association Accredited Affiliated with Christian Camping International (CCCA) Licensed by State of Oregon Phone:503-897-2447 Fax:503-897-4116 Web:www.upwardboundcamp.org Email: upward.bound.camp@gmail.com

HEALTH DISCLOSURE/PHYSICIAN APPROVAL

Patient Birthday: ___________ Gender: _________ Date of this Exam: ______________ Name of Patient:
(First) (MI) (Last)

Please use back for additional information.

Emergency Contact: _________________________________ Relationship:_________________________ Cell Phone:____________ Address:______________________________________City:________________State:_________ Zip:____________ Phone: ________________________ Email:_________________________ Alternate Contact: ___________________________ Height: _________ Weight: _______ BMI: ________ Blood Glucose _______Todays Blood Pressure:___________ BP HX: _______ Immunizations Current: Yes No Date of last Tetanus: __________ Patient prescribed regular medications: YES NO Please note the following as basis for recommendations/ restrictions while at camp. Upward Bound Camp provides recreational opportunities for persons with intellectual and developmental challenges ages twelve through geriatric. In operation since 1978. Accredited. Activities include but are not limited to, overnight sleeping in bunkhouse or tent style sleeping arrangements with others in peer group, large and small group recreational & educational activities in ratios of 1 staff to two-five campers. Campers choose to participate in a wide range of physical activities not limited to fishing, hiking, swimming, paddle boating, arts & crafts, drama, music, cooking outside, archery, dancing, table games, bowling, basketball, volleyball, nature study and horseback riding. All camp staff possess advanced first aid/CPR training, and trained in administrating oxygen, AED and epinephrine. There is an EMT and a nurse on duty. Describe nature of disability if known: Date of last physician review of medications: _________ Is camper currently under the care of a mental health professional? Yes No If yes, please give name and contact information: ______________________________________________________ Is camper currently under care of a dentist/orthodontist? Explain. Observations or recommendations for residential care needs: Please list past serious injuries/bone breaks or operations: Indicate Significant Physical Findings/Conditions: Eyes ____R ____L Ears ____R ____L Nose/Throat __________ Spine___________ Legs ___________ Feet _________________ Arms/Wrists_____________ Skin/Scalp ______________________ Abdomen _______________ Genitalia __________ Chest________ Heart ___________________ Lungs ____________ Teeth _______ General Disposition ______________________________________ Significant Health History (swallowing difficulties, heart condition, fragile bones, allergic reactions, asthma, tubes in ears, bleeding/ clotting disorders, chronic UIs, Hepatitis, appendectomy, etc):

Childhood/past illness/diseases:

Is current physician care routine or in response to chronic conditions? Explain:

Please note any common PRN medication(s) not recommended or specifically contraindicated for this patient.

Please list any conditions requiring hospitalization in past ten years:

Supportive devises/equipment needed/recommended:

I have examined the person herein described on ____________ (date) and have reviewed the health history information provided. It is my opinion that this camper is physically able to engage in camp activities, except as noted below: I have examined the person described herein and have reviewed the health history information provided and have the following reservations regarding camp attendance: Physician Name Printed: _________________________________ Phone: __________________ Email: _______________________ Physician Signature:_____________________________________ Address:_______________________________________________