Breathe DC

Camp Breathe Happy Camper Application

IMPORTANT: All campers MUST have a current Asthma Action Plan and Immunization Record to attend Camp. You may upload them with this application or send them later by fax, email or mail.

2017 Camp Breathe Happy Application

Child (Camper) Information


IMPORTANT: All campers must be DC residents. We will not approve your application if your child is NOT a DC resident.

IMPORTANT: All campers must have an asthma diagnosis. We will not approve your application if your child has NOT been diagnosed with asthma.

IMPORTANT: Applicants for Camp Breathe Happy must be first-time participants. We will not accept children who have attended camp in the past.

Age on 7/30/2017
Age on 8/3/2017

IMPORTANT: Camp Breathe Happy is for children ages 8 to 12. All campers must be at least age 8 on 7/30/2017. Campers who will turn 13 during camp are not eligible, so your child must be no older than 12 on 8/3/2017. We will NOT approve your application if your child does not meet the age requirement.


Parent/Guardian Information



Emergency Contact Information



Health Insurance Information



Background Information


Parent or guardian, please share your thoughts on the following questions.

Limit 50 words
Limit 50 words
Limit 50 words
Limit 50 words

Child's Health History


Enter a number. If none, enter zero.

Please tell us the dates and reasons for hospitalizations in the past year. List the 3 most recent hospitalizations, for any reason.

Date
Reason
Date
Reason
Date
Reason
Enter a number. If none, enter zero.
Date
Reason
Date
Reason
Date
Reason
If not, please enter None.

Please list all medications your child takes. Include injectable drugs if these are needed.

Medication #1 Name
How much (dose)
How often
Purpose
Medication #2 Name
How much (dose)
How often
Purpose
Medication #3 Name
How much (dose)
How often
Purpose

How often does your child experience the following side effects from his/her medications?

How often?
How often?
How often?
How often?
How often?
How often?

I hereby grant permission for my named child to receive any medication listed below on this form, as deemed necessary. I have checked those medications I wish to be made available to my child. I understand that generic equivalent medications will be used in place of more expensive brand-name items.



IMPORTANT: Please provide a copy of your child's Asthma Action Plan and Immunization Record. You may attach these here or send them by mail, email or fax.


Drop a file here or click to upload Choose File
Maximum upload size: 2MB
Accepted file types: JPG, PDF, .doc, .docx

 
Drop a file here or click to upload Choose File
Maximum upload size: 2MB

Other Comments



Thank you! This information will help acquaint us with your child prior to camp and will assist us in providing a positive camping experience for him/her!


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