IMMUNIZATION HISTORY. List the month/day/year the child received each of the following immunizations. Please fill in all empty boxes as required by state law. If you do not have an immunization record for your child, contact your doctor or local public health department to obtain the records. Visit xxxxx://xxx.xxxxxxx.xxx/PR/xxxxxxXxxxxx.xx?language=en and enter your child’s name and social security number for a state immunization record for your child. Signature of Parent / Guardian Date IF THE CHILD MEETS ALL REQUIREMENTS sign at arrow below and return this form to Wisconsin Youth Company, OR IF THE CHILD DOES NOT MEET ALL REQUIREMENTS check appropriate box below, sign and return this form to Wisconsin Youth Company. Although the child has not received all required doses of vaccine for his or her age group, at least the first dose of each vaccine has been received. I understand that it is my responsibility to obtain the remaining required doses of vaccines for the child WITHIN ONE YEAR and to notify Wisconsin Youth Company in writing as each dose is received. NOTE: Failure to stay on schedule or report immunizations to Wisconsin Youth Company may result in court action against the parents and a fine up to $25 per day of violation. For health reasons this child should not receive the following immunizations (List in chart above any immunizations already received.): Physician’s Signature: For religious reasons this child should not be immunized. (List in chart above any immunizations already received.) For personal conviction reasons this child should not be immunized. (List in chart above any immunizations already received.) I do not authorize the use of insect repellent on my child during program hours. Vaccinations - required for 5 years and older 1st 2nd 3rd 4th 5th Vaccinations - required for 4 year olds 1st 2nd 3rd 4th DTP Diphtheria, Tetanus, Pertussis DTP Diphtheria, Tetanus, Pertussis Polio (IPV) Polio (IPV) Hepatitis B Hepatitis B Measles, Mumps, Rubella (MMR) Measles, Mumps, Rubella (MMR) Varicella (Chicken Pox) Has the child had Varicella (chicken pox) disease? If yes, vaccine not required. Year: If no or unsure, vaccine required. Varicella (Chicken Pox) Has the child had Varicella (chicken pox) disease? If yes, vaccine not required. Year: If no or unsure, vaccine required. Hib (Haemophilus Influenzea Type B) Pneumococcal Conjugate Vaccine Directions: Please complete this form in its entirety. A review by parents/guardians and staff is required annually. This form r...
IMMUNIZATION HISTORY. This is a record of dates of basic immunization and most recent booster doses. DTaP, DTP, DT, Td Date Date Date Date Date Polio Date Date Date Date Date MMR Date Date Date Hemophilus Influenzae type b (Hib) Date Date Date Date Hepatitis B Date Date Date Date Varicella Date Date Pneumococcal Conjugate (PCV) Date Date Date Date Date Other Date Other Date Other Date MEDICAL EXAMINATION – To be filled out by licensed physician. Examination is acceptable when performed no more than 12 months prior to arrival at camp. Code: S = Satisfactory X = Not Satisfactory (Explain) 0 = Not Examined General Appearance Genitalia Height Weight Blood Pressure Posture & Spine Throat - Tonsils Nose Teeth Abdomen Hernia Feet Lungs Skin Hgb. Test (Date) Urinalysis (Date) Eyes Vision w/Glasses Extremities Heart Ears Hearing Neurological Findings Describe Abnormal Findings and/or Handicapping Conditions Allergy: (Please specify) Recommendations and restrictions while in camp: Special Diet Special Medicine (dose, route of administration, when should it be administered) Is parent/guardian sending special medicine? Activity Restrictions Swimming Diving General Appraisal: I have examined the person herein described, reviewed his/her health history and it is my opinion that he/she is physically able to engage in Day Camp/Year Round Afterschool and Youth Center activities, except as noted above. M.D. EXAMINING PHYSICIAN (SIGNATURE) PHYSICIAN'S NAME (PLEASE PRINT) Telephone Address Date of Examination
IMMUNIZATION HISTORY. Provide the month and year for each immunization. Starred (*)immunizations must be current. Copies of immunization forms from health-care providers or state or local government are acceptable; please attach to this form. Diptheria, tetanus, pertussis (DTaP) or (TdaP)* Mumps, Measles, Rubella (MMR)* Haemophilus influenzae type B (HIB) Hepatitis A Tetanus booster (dT) or (TdaP) * Polio (IPV)* Pneumococcal (PCV) Meningococcal meningitis (MCV4) Varicella vaccine (chicken pox) Had chicken pox ❑ Yes ❑ No Tuberculosis (TB) test ❑ Negative ❑ Positive Hepatitis B: 1 2 3 Hepatitis B Series must be in compliance prior to attendance at camp. If your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being fully immunized. Signature of Custodial Relationship Parent/Guardian Date: to Camper: What have we forgotten to ask? Please provide in the space below any additional information about the camper’s health that you think important or that may affect the camper’s ability to fully participate in the camp program. Attach additional information if needed. Signature of Custodial Relationship
IMMUNIZATION HISTORY. The complete physical examination, also known as the Initial Physical Exam (IPE), shall include:
