Health History and Special Needs

IMPORTANT INSTRUCTIONS:

Application for participant will not be considered complete without medical insurance information.

Fill out this form only once per participant. If you or your camper is attending multiple camp sessions or overnight trips, please select all the applicable sessions below.

FAMILY CAMP: Please fill out this form for every member attending camp; your registration will not be complete without each family member's health history and special needs form.

PARTICIPANT INFORMATION

Which activities are you planning to participate in:(Required)

Alumni (Adult) Camp at Lions Camp at Teresita Pines: June 8-12

Youth/Teen Camp at Pathfinder Ranch: June 17-22

Family Camp at Mount Kare: July 1-5

Participant's Name(Required)

First Last

Date of Birth(Required)

Age(Required)

Emergency Contact Name(Required)

First Last

Relationship to Participant(Required)

Emergency Contact Email(Required)

Enter Email Confirm Email

Emergency Contact Phone(Required)

Secondary Emergency Contact Phone(Required)

PHYSICAL MOBILITY NEEDS

PHYSICAL: Does the participant use any of the following?(Required)

Please select all that apply.

Walker

Crutches

Wheelchair

Has trouble walking/standing for long periods of time

None of the above

Please provide more details:(Required)

PERSONAL CARE NEEDS

INDEPENDENCE: Does the participant need assistance with any of the following?(Required)

Please select all that apply.

Requires assistance with feeding

Requires assistance with using the bathroom

Requires assistance with showering

Requires assistance with dressing

Requires assistance ambulating (walking)

Requires assistance communicating

Has a history of bedwetting

Requires assistance with tasks other than those listed

None of the above

Please provide details:(Required)

DIETARY NEEDS AND ALLERGIES

DIETARY NEEDS:(Required)

Please select all that apply.

Vegetarian

Vegan

Dairy / Lactose Free

Gluten Free

Other Food Allergies

None of the above

Please provide details:(Required)

Allergies

Please select allergies below:(Required)

Please select all that apply.

Bee stings

Insect Stings

Latex

Peanuts

Tree nuts

Dairy / Lactose Intolerance

Penicillin

Allergies to medications not listed

Allergies to food not listed

Any other allergies not listed

No allergies

Insect Stings: Please provide more information(Required)

Allergies to medications not listed:(Required)

Allergies to food not listed:(Required)

Any other allergies not listed:(Required)

DISABILITIES OR MEDICAL CONDITIONS

Camper's Vision(Required)

Does the participant have any of the following:(Required)

Please select all that apply.

Cerebral Palsy

Multiple Sclerosis

Muscular Dystrophy

Intellectual Disability

Down Syndrome

Autism

ADD/ADHD

Emotional Disorders

Depression

Anxiety

Eating Disorder

Behavioral Disorder

Psychiatric Condition

Seizures

Epilepsy

Diabetes

Anaphylaxis

Deaf or Hard of Hearing

Anemia

Cancer

Stroke

Heart Disease

High Blood Pressure

Heart Attack

Irregular Heartbeat or Heart Murmur

Sickle Cell Disease

Hemophilia

Blood Clots

Thyroid Disease

Kidney Disease

Ear Infections

Sinus Infections

Bladder Infections

Mononucleosis

Chicken Pox

Mumps

Pneumonia

Skin Conditions

Alcohol Use Disorder

Drug Addiction

Asthma

Other disabilities not listed

Other medical conditions not listed

Other psychiatric or mental health conditions not listed

None of the above

Intellectual Disability: Please provide more details(Required)

Emotional Disorder: Please provide more details(Required)

Depression: Please provide more details(Required)

Anxiety: Please provide more details(Required)

Eating Disorder: Please provide more details(Required)

Behavioral Disorder: Please provide more details(Required)

Other disabilities not listed:(Required)

Other medical conditions not listed:(Required)

Other psychiatric or mental health condition not listed:(Required)

Seizures or Epilepsy

Date of Last Seizure(Required)

Typical seizure duration:(Required)

Frequency:(Required)

Potential triggers:(Required)

Asthma

Date of last attack:(Required)

Inhaler(Required)

Uses an inhaler

Does not use/need inhaler

Potential triggers:(Required)

Medication

Does the participant have an EpiPen?(Required)

Yes

If you carry an EpiPen, please list the specific allergy (e.g., peanuts, insect stings) that requires its use.(Required)

Does the participant take medication?(Required)

Yes

Medication Details(Required)

Please list all medications and dosage details below. Use the + sign on the right to add more fields for each medication.

Do any of the medication need refrigeration?(Required)

Yes

Tuberculosis Screening

Participants in the Recreation Program at Wayfinder Family Services no longer need to submit a negative TB skin test to attend organized overnight activities. Please answer the screening questions truthfully, and Wayfinder staff will contact you if further steps are required before attending an organized overnight activity. Thank you.

Have the participant ever had a positive skin or blood test for TB?(Required)

Yes

Have the participant ever been told they have an abnormal chest x-ray?(Required)

Yes

In the last 2 years, have the participant lived with or spent time with someone who has been sick with TB?(Required)

Yes

Have the participant lived or traveled to Africa, Asia, Pacific Islands, Central America, South America, Mexico, Eastern Europe, The Caribbean, or the Middle East for more than one month?(Required)

Yes

Insurance Information

Please upload a photo of your participant's insurance/Medi-Cal card. If you are unable to upload, please send via email.

Insurance/Medi-Cal information

Max. file size: 50 MB.

Electronic Signature:(Required)

TERMS & CONDITIONS

Authorization for Third Party to Consent to Treatment of Minor Lacking Capacity to Consent

This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/ or an examining physician.

I, the undersigned, parent/legal guardian of the aforementioned camper, do hereby authorize Wayfinder Family Services, Camp Bloomfield and its employees as agent (s) for the undersigned to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care, which is deemed advisable by, and is to be rendered under the general or special supervision of, any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

The undersigned understands and agrees that Wayfinder Family Services, Camp Bloomfield and its employees shall not be legally or financially liable for any claim arising from any medical care or dental care provided pursuant to this authorization. The undersigned hereby agrees to indemnify and to hold Wayfinder Family Services, Camp Bloomfield and its employees harmless from any claim made by or on behalf of said minor arising out of any medical care or dental care provided pursuant to this authorization.

This includes authorization to consent to any X-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care, which is deemed advisable by and is to be rendered to the minor by or under the supervision of a dentist licensed under the provisions of the Dental Practice Act. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority to power on the part of our aforesaid agent (s) to give specific consent to any and all such diagnosis, treatment or hospital care which a physician, meeting the requirements of this authorization, may, in the exercise of his/her best judgment, deem advisable. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.

I hereby authorize any hospital which has provided treatment to the aforementioned camper pursuant to the provisions of Section 25.8 of the Civil Code of California to surrender physical custody of such minor to my above-named agent (s) upon the completion of treatment. The authorization is given pursuant to Section 1283 of the Health and Safety Code of California. This authorization will remain effective while the aforementioned camper is involved or participating in any Wayfinder Family Services, Camp Bloomfield program or activities, unless revoked in writing by the undersigned and delivered to the aforesaid agent (s).

CALIFORNIA CIVIL CODE SECTION 25.8

S25.8 Minor- Consent to Furnishing of Hospital or Medical Care by Adult other than Parent - Lg. H. 1965 ch.1524

Either parent if both parents having legal custody, or the parent or person having legal custody or the legal guardian, of a minor may authorize in writing any adult person into whose care the minor has been entrusted to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to said minor under the general or special supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medicine Practice Act or to consent to any X-ray examination, anesthetic, dental or surgical diagnosis or treatment and provisions of the Dental Practice Act.

Type your full name to sign.

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Program Areas

IMPORTANT INSTRUCTIONS:

PARTICIPANT INFORMATION

PHYSICAL MOBILITY NEEDS

PERSONAL CARE NEEDS

DIETARY NEEDS AND ALLERGIES

Allergies

DISABILITIES OR MEDICAL CONDITIONS

Seizures or Epilepsy

Asthma

Medication

Tuberculosis Screening

Insurance Information