Fillable MY CAMP MEDICAL SUPPLEMENT (Epilepsy Foundation)

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MY CAMP MEDICAL SUPPLEMENT (Epilepsy Foundation)

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MY CAMP MEDICAL SUPPLEMENT
© 2019 Epilepsy Foundation of America, Inc.
05/2019 711CMS Page 1 of 3
Personal Information
Camper’s Name: ___________________________________________ Date of Birth: _________________________
Address: _______________________________________________________________________________________
Parent / Guardian Name: __________________________________ Relationship to Camper: __________________
Address (if different from camper): _________________________________________________________________
Parent / Guardian Phone Numbers: Home: _______________ Work: _______________ Cell: _________________
Alternate Contact: _______________________________________ Relationship to Camper: __________________
Alternate Contact Numbers: Home: _________________ Work: _________________ Cell: ___________________
INSTRUCTIONS: Complete the following information to help give the camp staff a better idea of the
camper’s seizures and other health concerns. Review this form, in addition to the seizure response plan,
with your or your child’s health care team and with camp staff.
HEALTH PROBLEMS: Please list the types of seizures that the camper has and any other health
problems. Include any problems that may affect safety or an ability to participate in camp activities.
SEIZURE DESCRIPTIONS: Describe in your own words what each type of seizure looks like. Include
any warning, seizure behaviors, and what happens after the seizure.
Seizure Type 1:
Seizure Type 2:
Seizure Type 3:
MY CAMP MEDICAL SUPPLEMENT
© 2019 Epilepsy Foundation of America, Inc. 05/2019 711CMS Page 2 of 3
SEIZURE TRIGGERS: Are there any factors that seem to make your child more likely to have a seizure? Do
seizures occur at any specific time of day or night, or are there any other patterns to his or her seizures? Please
include plans for how these triggers are managed, the need for special accomodations, and tips for staff.
1) Mood, behavior, learning, or attention: Be sure to include any other cognitive problems that staff should
know about and how they are managed. Inlcude the need for special accomodations and tips for staff.
OTHER PROBLEMS: Please describe any problems that may affect your child in the following areas:
2) Movement or ability to walk: Note if there are problems with weakness, balance, coordination, or other
problems. Include any mobility aids that are used and special accomodations needed to get around safely.
3) Senses: Note if there are problems with feeling (hot, cold, pain, etc.), vision, smelling, tasting, or hearing.
Inlcude any special accomodations and tips for staff.
4) Communication: Note if there are difficulties speaking, understanding, or writing. Include alternative
methods of communicating and any other special accomodations and tips for staff.
5) Social Skills: Note if there are problems with social skills or interacting with peers. Include and special
accomodations and tips for staff.
6) Other Concerns or Problems:
MY CAMP MEDICAL SUPPLEMENT
© 2019 Epilepsy Foundation of America, Inc. 05/2019 711CMS Page 3 of 3
TREATMENT INFORMATION: Please list any medications or other treatment used for a seizure. Attach a
medication schedule that lists how each medicine is given and at what times. Talk to the camp nurse (or
director) to make sure that the right amount of medicine is available. Include any special instructions.
PLANS FOR RESPONDING TO SEIZURES: Please describe what is done when a seizure occurs. Include any
special first aid interventions. Be sure to include if there is a risk for a seizure emergency and if ‘as needed’ or
rescue treatments are prescribed. Comple a seizure response plan and attach to this form.
1) Safety Risks: Please note any safety risks the camp staff need to know about. Include fall risks and other
seizure behaviors that may increase risk of injury. Include any medication side effects.
Safety Plans:
2) Rescrictions of Camp Participation: Please list all activities that the camper may not participate in and any
activities that may need special accomodations (for example special equipment or 1-1 supervision).
3) Adaptive or Safety Equipment: Please list any equipment or adaptive aids that is used to help move
around safely or prevent injury in other ways. Note when these aids should be used and other instructions for
staff.
4) Other Safety Precautions: Please describe any other safety precautions that should be used for seizures or
other health problems. Note if there are certain times that specific activities should be avoided and if alternative
activities may be needed.,
If specific precautions or equipment is needed, you may be asked to get specific orders from your
health care team. Review any restrictions and precautions if your health care team.
Thank you for your help!
Date form was completed: __________________________________
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MY CAMP MEDICAL SUPPLEMENT (Epilepsy Foundation)

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Completed 31 July 2021

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