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Appendix 6:
Health Care Consultant Agreement
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— • HEALTS CARE CONSULTANT AGREEMENT
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NAIVIE OF CAMP ADDRESS OF CAMP
' The Massachusetts DepartmeIIt of Pnblic Hea.tth regulafions for recreational camps for chi.Tdren,105 CiVIlZ
� 43 0.400,require tbat atl reereational camps for children have a healtb�care consuttant.'�e reg¢tation an.d
zesponsibilities of thi�s person are described betow. �
430.159(A)Healt�Care Consultant A designa#ed Massachusetts licensed physician,nnrse praafi�ioner or
� physician assistaat with pediatric txaixung as the camp's healtti care consultant.The consultant shall:
1. .Assist in tT�e development of the camp's health care policy as described in 105 CMR 430.159(B);
2. Review and app�rove the policy initiaily and at Ieast annually tb.ereafter;
3. Approve a.ny changes in t11e po�.cy; • '
4. Review and approve the fisst aid trasning of th.e statf,
5. Be available for consu.lfiation at all times;and
6. Develop and sign written orders to be foliowed by the on-site health supervisor in the admiuistration
of hi.s/her related duties. �
I.f the�iealth supervisor is not a licensed health care professio�al autharized to administer.prescription
' medications,the a�im�nict,�ation of inedications shall be under the professional oversight ofthe health care -
consultant.105 GMR 430.160(C)
430.159(B)Health Care Poiidv A written medical policy,approved by th,e Iocal board of health and by�the
.camp health care consuitant Such policy shall include,but not be limited to,daiJy health supervision,infection .
control,handling of healfih e�margenczes and accidents,available anabulance services,pravision for medical,'
� � nursing and first aid servir.es,the name af fihe designated on-site camp health supervisor,the name,address
and phone number of the camp health care consultant required by 105 CMR 43 0.159{A)and tl�e nama of fihe
health stipervisor requirad by 105 CMR 430.I59(E),if applieable. •
430.160(G�Admixustration af Medication Tbe health care consultant slaall acl9aowledge iu wzitiug a Iist of all
medications admittistered a#tb.e eamp. •
� I meef the requSrements of the health care consultant as described in 105 CMR 43Q.159(A). I have reviewed
theses referenced regulations and understand the responsibilities of the position and agree to assist this camp'
regarding the same. - �
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Print Name Title
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' e MALiczuse/RegistrationN�b'er
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,�� �l� s;���t���Ct;� � �,.�,;,��.� ���- t� l� �C�
Address �
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Teleplione Nmnbex Date
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�' Healt�Z Care Consultant AclrnawIedgement of On-Site Nledicatioz�s
I, ! ��1, �` �� c�`"��'^�'�e- acknowledge that I sezve
� . Print name of Health Care Consultant ,
as the Health Care Consultant for: �
� � �Print name of Camp '
As such,X hereby authorize fhe following listed medications to be ad�mi.aistered to campers as .
� prescrtbed,grovided that,�e medications.are delivered to the camp,maintained by the camp,�d '
admi�istered in accorda�zce wzth Commonwealth of Massachusetts Regulations at 105 CMR 43Q.160 '
and t$at the parendguardian of the camper has provided written permission for the administration •
. of the medication. ' '
F am not the prescribing physiczau fax these med'xcations.My signature indicates only tliafi T have �
' revlewed the lis�ed inedications an.d associa�ed potentiat side effects,.adverse reactions and other
pertment information with all personnel administering medications to cam.pers and not that I have
revievved or determined the appropriateness of the medica.tions for tlae camper.My signature
f�u�tb.ex ac�Cn.owledges that aIl personnel listed below,who administer�onedications afithe camp,are
eithe�liceused health oare providers authorized to administer medications or designa#ed health care
super,visors wha are appropriately trained to and are doing so un;dar my professianal oversight.l �
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' Names of individual{s)authorized to admi.nister medications at camp: ' . �
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� � I �<�.�-^''1 `''�I��'�� Date: � ��I ��
. 5ignature Heal�Care Consultaut -
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Updat�d 7anuazy 2000 to reflect the amendme»ts#o"ReguIaiions for Minimnm Standazds for Recreational Cam�is for
� Children,Sta#e Sanitary Code,Chapter IV"I05 CMR 43Q.000.
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. ' t See advisory doetrment of the Massachusetts Department of Publio Health.—"Guidelines for the
Storage and Administration of Medication in Camps" � �
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If renewal,license#YCYGO Camp Name �L/v9/jFWFf�t J 1���'S Page 5 of 5
If renewal,list name of camp exactly as it appears on last license issaed.
� MEDICAL C+� RAGE CERTIFICATIOI�T
. Pursuant to Sectio 19-13-B27a(j)of the Regulations of Connecticut State Agencies a physician shall be on call and responsible for
all healthcare incf ding fcrst aid. 1'he camp physician must hold a current Connecticut medical license.Note:Any physician or
. surgeon who hold a license in goad stianding in another state may practice as a youth camp physician in this stafie without a •
' �onnecticut licens for a period not ta exceed nine weeks.This page may be duplicated if more tl�an one physic[an is responsibfe
far the camp.
First Name �� � ` Last Name ��-��'� �--
Aaa��s� �� `
� U�� �T�1C_�-F'JV� City� � ��� State ���"�1
Zip Code � �a" '(� Fhysician's Phone Number{���j ) ,..�r� � �'(��
_ I understand tha g am responsible for the pianning of emergency care,including sapervisian of camp heatth staff;a review
of health care pro edures;preparing written standing orders for licansed medicul persannel,specifying first aid ins#ructions
for unlicensed pe sannel(first sid instructions for an uniicensed medical persnnnel cannot list any medications) and�rst
aid equipmenE; �viewing,signing and dateng the bound log on a weekly basis; and proceduxe xznplementatian ta maintain
records on presc 'ptian drugs nsed at the above named camp. This is to certify that T have accepted the posit3on af camp
pt�ysician on call far the abave named camp and will assume responsibilify for all camp sessions for the cluraEion of the
license. �
Lieense# �-����� � / !� !�
Physician's�igra ture Physician's License# Date Signed
� **��x�x*�x��**x�* �:�x*��x����*��*:��x*�����*��***����������:�*�x*����x:����x��x���*���x*�x:���x��:����:���x�*�x�x*�x��*�x
OPERA7COR CERTIFICATI4N
I certify that all f the above statements contained harein are true and correot to the best of m.y knowledge.I pramise to
uphold aud main ain atl standards requi:ed under the Connecticut G,.neral Statutes and Regulat�ons cf Connecticut State -
Agencies gove � ' g the licensure and operation Qf & y011trl camp available on the Agency website @
' h ://www.ct. o loeelcam s.Az�y false statements made herein are puaaishable in accordan.ee with Sections S3t�.-157 and
19a-423.
' First Name Last Name � Title � -
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,S`ignature nf the pe�ator(Owner}or andividual authorized to act o�a behal'f o�'the Operatortawner Date Sigr�ed
A com leted a lication is due 30 da s rior ta Ehe o enin date of our cam .The licenstrre fee iu�the form of a
check or money order made payabte to tl�e Treasurer,State of Connecticut must accompany the appl�cation.All
� fees are non-re undable. 1GIai1 complated and signed application alang with payment to the Uf#ice of�arly
Chaldhaod,Divi ion of Licensang,Yautl�Camgs,45U Columbus Baulevard,Suite 30z,Har�ford,Cx`06103.
Pdease r taira a copy of the application beir�g subnzi�tecl to the Office of Ea�ly Chiddliaod
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