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Camp Starlight

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Camp Starlight

Camp Starlight provides a safe, caring, spiritual and FUN camp experience for children whose lives are affected by HIV/AIDS

MedicalExamination

Camp Starlight

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CAMPER MEDICAL EXAMINATION

THIS PAGE MUST BE COMPLETED BY A LICENSED MEDICAL PERSONNEL
A. OVERALL ASSESSMENT

Date of Physical Exam
Clinical Diagnosis:
. TUBERCULOSIS (TB) SKIN TESTING OR INTERFERON GAMMA RELEASE ASSAY (IGRA)

The American Academy of Pediatrics recommends annual TB skin tests for all HIV-infected children; it is also recommended for children who reside with HIV-infected adults. TB testing information is required for the child’s participation. A TB skin test result must be documented within the past 12 months. This is an absolute requirement!

Most recent TB Skin Test OR IGRA
Chest x-ray (If test positive or hx of disease)
Date
SIGNATURE OF LICENSED MEDICAL PERSONNEL
Address
Phone
Emergency Phone
MEDICATIONS
Please list ALL medications (including over-the-counter and/or non-prescription drugs) taken routinely. Bring enough medication to last the entire week of camp. Keep all medications in their original packaging/ bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration.

This person takes NO medication on a routine basis.
Thank you!
  • Home/
  • About Camp/
    • Overview
    • A new chapter
    • Our team
    • Our mission
  • Registration/
  • Get involved/
  • Contact/

Camp Starlight

Camp Starlight provides a safe, caring, spiritual and FUN camp experience for children whose lives are affected by HIV/AIDS

Camp Starlight| (503) 964-1516 |info@camp-starlight.org |© 2014, Camp Starlight, Inc.  All rights reserved.