Camp Wheeze Away Registration | Allergy and Asthma Specialists, PSC

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Name*

First Last

Prefers to be called:*

First

Parent/Gaurdian Email*

Child's Date of Birth*

Grade in School Fall 2024*

Sex*

Male
Femal

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Please List the Names and Phone Numbers for Two Emergency Contacts*

Child's Physician*

How long has your child had Asthma?*

What are your child's "triggers"?*

How many asthma attacks has your child had in the past 12 months?*

Did these attacks require a physician office visit, Emergency Room visit or Hospitalization? If so, list what type of visit and number of visits.*

When was your child's most recent hospitalization?

Has your child ever experienced a respiratory arrest or been placed on a ventilator? If yes, please summarize details.*

What are your child's "Early Warning Signs"? (Check all that apply.)*

Any other "Early Warning Signs" not listed above? (Please specify)

Is your child allergic to any foods?*

Yes
No

If yes, please list below and describe reaction:

Any other allergies? (For example, latex allergy or bee stings)*

Does your child have an Epipen or Epinephrine Autoinjector?*

Yes
No

What medications does your child take on a regular basis? Please list medication name, dosage and times given.*

If your child requires any medication during his stay at Camp Wheeze Away, please give the medication to one of the Camp Coordinators each morning before Camp begins. The medicine should be kept in its labeled prescription container. Do not forget to send your child’s emergency medications! Thank you.

What medication does your child normally take for acute attacks?*

Does your child use an inhaler?*

Yes
No

Does your child use their inhaler independently: (example: at school)*

Yes
No
Not Applicable

What information would you like to have that will help you or your child to better manage their asthma?

Does your child have any other illnesses? If yes, please explain:*

Does your child have any physical limitations? If yes, please explain:*

Does your child know how to swim?

Yes
No

Has your child ever had swimming lessons? If yes, please list when and where:*

How would you rate your child's ability to swim?*

Code of Conduct*

Our goal is to provide a safe, informative, fun camping experience for every child. All campers are expected to behave in a safe, respectful manner and participate in all activities. If your child is disrespectful, or willfully disobeys instructions or behaves in an unsafe or disruptive manner; then, we will contact you to come to the Camp immediately and remove your child from the premises.
Due to the nature of food allergies, your child will not be allowed to bring any outside food or beverages to camp. If your child does have any outside food or beverage, we will contact you and we will dismiss him/her immediately. Your child will not be allowed to return to camp. We apologize for any inconvenience this may cause, but food allergies can be fatal to some of our participants.
Camp Wheeze Away is not responsible for any lost or stolen items.

I acknowledge that I have read and fully understand and will abide by the policies and expectations outlined in this registration form.

Name

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