Camp GLOW

Students Name ________________________________ Family Name

______________________________________

1. Does the student have a medical problem with any of the following? /
:
Eyes/
Skin/
Stomach/
Ears/
Teeth/
Liver/
Nose/
Legs/
Hernia/
Throat/
Arms/
Ankles, Knees/ ,

Explain any problems indicated above. /

. ______________
___________________________________________________________________________________________
_
2. Does the student currently have any of these illnesses or conditions? /
?
Bed-wetting /
Bleeding disorders /
Asthma /

Nightmares / Fainting /
Diabetes /

Heart conditions /
Convulsions /
Other/

_________
Explain any problems indicated above. /
. ______________
___________________________________________________________________________________________
_
3. Does the student have any condition that may require special care or food? If so, please
explain. / ?
, . __________________
___________________________________________________________________________________________
_
4. Is the student allergic to any of the following? / :
Which ones? / ?
What is the reaction? /
?
Food /
Medicine /

Plants /

Insects /

5. Does the student take any medication regularly? If so, please explain below. /
? ,
.
Medication /
Dosage /
Needs refrigeration /

Appendix D~3

Camp GLOW

6. Are there any activities or sports which the student may not take part in? If so, please
explain. / ?
,
.________________________________________________________________________________
_
My child is approved to participate in hiking, sports, water, and all activities unless noted by
me above. In an emergency, I give permission for camp medical personnel to provide medical
care to my child. If you agree, please sign here.
, , , , .
,
. , .
Parents Name_______________________________ Signature____________________________ Date
_________

Students Name ________________________________ Family Name

______________________________________
Emri i vajzs

Emri i familjes

7. Does the student have a medical problem with any of the following? / A ka vajza juaj
ndonj problem mjeksor me t poshtshnuarat?
Eyes/ syt
Skin/ lekurn
Stomach/ barkun
Ears/ vesht
Teeth/ dhmbt
Liver/ mushkrin e zez
Nose/ hundn
Legs/ kmbt
Hernia/ hernia
Throat/ fytin
Arms/ kraht
Ankles, Knees/ nyjet ose
gjunjt
Explain any problems indicated above. / Prshkruani ndonj problem nga t
lartshnuarat. ___ _____________
___________________________________________________________________________________________
_
8. Does the student currently have any of these illnesses or conditions? / A ka vajza juaj
ndonj nga kto smundje ose kto gjendje?
Bed-wetting / lagje e shtratit
Bleeding disorders/
Asthma / astma
gjakderdhje
Nightmares / ankth
Fainting / humbje e
Diabetes / diabet
vetdijes
Heart conditions / smundje
Convulsions / epilepsi
Other/ t tjera
zemre
________
Explain any problems indicated above. / Prshkruani ndonj problem nga t
lartshnuart. ______________
___________________________________________________________________________________________
_
9. Does the student have any condition that may require special care or food? / A ka vajza
juaj ndonj gjendje ose problem n ushqim e cila kerkon ndonj prkujdesje t veant?
Jo Po Nse po, prshkruani ktu. ______

Appendix D~3

Camp GLOW
___________________________________________________________________________________________
_
10.Is the student allergic to any of the following? / A ka vajza juaj ndonj alergji nga t
poshtshnuarat:
Which ones? / Cilt?
What is the reaction? / Cilt jan
reaksionet?
Food / ushqim
Medicine /
barrat
Plants / bim
Insects /
insekte
11.Does the student take any medication regularly? If so, please explain below. / A prdorn
vajza juaj barra? Jo Po Nse po, prshkruani n t poshtshnuarat.
Medication / Emri i barit
Dosage / Doza
Refrigeration / A duhet t ruhet ne
frigorifer?
Jo
Po
Jo
Po
12.Are there any activities or sports which the student may not take part in? If so, please
explain. / A ka ndonj aktivitet ose sport t cilat nuk iu lejohen vajzs suaj? Jo Po
Nse po, prshkruani ktu. _________________
___________________________________________________________________________________________
_
My child is approved to participate in hiking, sports, water, and all activities unless noted by
me above. In an emergency, I give permission for camp medical personnel to provide medical
care to my child. If you agree, please sign here. Vajza sime i lejohet t merr pjes n ecje,
sport, aktivitet ujore, dhe t ngjajshme, prve atyre q ua cekm m lart. N raste
urgjente, pajtohem q vajzs sime ti ofrohet ndihm nga personeli n kamp. Nse
dakordoheni, ju lutem, nnshkruani ktu.
Parents Name_______________________________ Signature____________________________ Date
_________
Emri dhe mbiemri prindit
Data

Nnshkrimi

Appendix D~3