Health FormHealth History for all participants (youth and adults) with the Diocese of Victoria group Sonlight Health Form 2024 - Diocese of Victoria Step 1 of 7 14% Camper Name First Last Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Contact Name First Last Primary Contact PhonePrimary Contact Email Secondary Contact Name First Last Secondary Contact PhoneSecondary Contact Email Emergency Contact 1: NameEmergency Contact 1: PhoneEmergency Contact 2: NameEmergency Contact 2: Phone Health Care ProvidersPrimary Care ProviderPhoneMay we contact health care providers? Yes No Physical Health HistoryAre there any activities from which the camper should be exempted or limited for health reasons? Yes NoPlease explain what activities should be exempted or limited and whyPlease check all that apply for the camper's health history: Allergies Asthma Diabetes Recurring Health Issues Operations or Serious Injuries Other Issues Travel Outside of US (in last 9 months) None of the above.If yes to any questions above, please add information here: Mental, Emotional, and Social HealthThank you for providing the information our health care staff will need to know to help your camper have the best camp experience possible. Information is only shared with the counseling staff on a 'need to know' basis.Has this individual gone through any significant family changes? (death, divorce, abuse, adoption, etc) Yes NoCommentsDoes your child have a Behavioral Health plan for school? Yes NoIf yes, please explainIs there anything you would like us to know so that we may work with you to provide the best camp experience for your child? Food Allergies / Intolerances and PreferencesSonlight Camp will provide the menu for your camper's week if requested. We do not have an allergen free kitchen, so we welcome conversation with you about your camper's food allergies before camp begins. Contact Mary regarding all food questions / concerns. [email protected] or 970.264.4379.Please list. dietary restrictions or preferences No Dairy No Gluten No nuts Vegan Vegetarian Other (explain below) No dietary restrictionsAllergy or Intolerance? Does this include butter? Please describe what happens when this individual has dairy.Allergy or Intolerance? Please describe what happens when this individual eats gluten.Allergy or Intolerance? Please describe what happens when this individual eats nutsDoes this individual carry epinepherine? Yes NoPlease list all other allergies, and describe what happens when this individual eats any of these foods.Comments MedicationsPlease list All medications (including over the counter or nonprescription medications) taken routinely. Bring enough medication to last the entire time at camp. Medications must be in the original packaging/bottle that identifies the prescribing physician (if a prescription drug) the name of the medication, dosage, and the frequency of administration.This camper will need regular medications while at camp. Yes NoMedicationsMedicationDose Given & WhenReason Add RemoveOver the Counter MedicationThe following medications are stocked in the health center.Can the camper take the following medications? Check for each approved medication. Acetaminophen (Tylenol) Antidiarrheal (Maalox) Bismuth Subsalicylate (Pepto-Bismol products) Calamine Lotion Ceterizine (Zyrtec, Aller-tec, Wal-tec) Chamomile Tea Chlorpheniramine Maleate (Robitussin Cough & Allergy Syrup) Cough Drops (Generic) Diphenhydramine (Benadryl) Guaifenesin (Mucinex¨ products; Robitussin Cough & Cold CF Liquid) Ibuprofen (Advil) Loratadine (Claritin products) Opcon-A (eye drops) Pediculosis Treatment (Nix, Lice Treatment) Poison Ivy Treatment (Ivy-Dry) Pseudoephedrine Hydrochloride (Advil¨ Cold & Sinus products) Refresh (Celluvisc) Tolnaftate (Tinactin) Terms and Condidtions'Parent/Guardian Authorization for Health Care: This health history is correct and accurately reflects the health status of the camper to whom it pertains. The camper described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child. I understand the information on this form will be shared on a ''need to know'' basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child's health record from providers who treat my child and these providers may talk with the camps staff about my child's health status.SignatureBy my signature I affirm that this health history is correct and complete to the best of my knowledge and that I have read, understood and agree to the Terms and Conditions specified in this form.