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CT Heart Camp Camper Medical Form

Child's First name*

Child's Last name*

First and Last Name of Parent or Guardian Completing the Form*

Medical Information

Primary Care Physician*

Primary Care Physician Phone

Name of child’s cardiologist*

YNHH / CCMC*

(If other please provide office location/phone number)

Child’s Cardiac Diagnosis*

Other medical problems (i.e. ADD, asthma, celiac, etc)*

Other specialist’s Name 1

Other specialist’s Specialty 1

Other specialist’s Phone 1

Other specialist’s Name 2

Other specialist’s Specialty 2

Other specialist’s Phone 2

Behavioral / Mental health specialist

Behavioral / Mental health specialist Phone

In the past 12 months has your child required surgery, procedures or hospitalization? *

Yes

No

If yes, please give date(s) and reason(s):

Allergens

Allergen (medications, foods, animals, insects, etc) 1

"Reactions* (be specific with the symptoms, how severe, when they start, etc.)" 1

Age of Last Reaction 1

Allergen (medications, foods, animals, insects, etc) 2

"Reactions* (be specific with the symptoms, how severe, when they start, etc.)" 2

Age of Last Reaction 2

Allergen (medications, foods, animals, insects, etc) 3

"Reactions* (be specific with the symptoms, how severe, when they start, etc.)" 3

Age of Last Reaction 3

What is your usual response to an allergic reaction (medications, ice packs, etc)?

Does your child have any special diet restriction or preferences (vegetarian, celiac, picky eater)?*

Does your child have any special needs or physical limitations? *

Does your child have any behavioral, developmental or emotional concerns? *

Yes

No

Does your child need special care or tutoring at school?*

Yes

No

Does your child need one-on-one supervision for activities/school? *

Yes

No

Does your child have an IEP or 504 plan at school?*

Yes

No

Has your child been to an overnight camp before?*

Yes

No

Is there something that scares your child?*

Yes

No

Is there anything else that you think we should know about your child?

Medications*

Medication, Strength, Time taken, Directions, Prescriber

Insurance

Does your child have health insurance?*

Yes

No

Name of Health Insurance Plan

Policy Holder

Policy and/or Group Number

Upload a copy of your insurance card for emergency purposes

Let's Connect

106 Doral Farms Rd.

North Branford, CT 06471

203-499-8242

info@joeabatefoundation.org

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