Camper Information:

Camper’s Name (required)

Birth Date

Age

Weight

Parent/Guardian #1:

Parent/Guardian #1

Address

City

State

Home Phone

Work Phone

Cell Phone

Email

Parent/Guardian #2:

Parent/Guardian #2

Address

City

State

Home Phone

Work Phone

Cell Phone

Email

Emergency Contact:

Name

Relationship

Home phone

Cell phone

Physician Information:

Name of Physician

Physician Phone Number

Insurance Information:

Do you carry medical/hospital insurance?
 Yes No

If so, carrier or plan name

Group # & policy
#

Name of insured

Phone

Allergy / Medical Information:

Allergies Please describe reaction & treatment

Is an Epi-Pen necessary?
 Yes No

Allergies to medications, reactions & treatments:

Allergies to foods, reactions & treatments:

Other Allergies (insect stings, asthma, etc.) reactions & treatments:

Medications: Please list all medications, taken routinely, including dosages.

Past History (Check if applicable)
 Epilepsy Diabetes Heart Trouble Asthma Nose Bleeds

Recent Surgery
 Yes No

Do any of these require attention at camp?

Date of last Tetanus Booster

Does the camper have any limitations on activities or medical problems that we should know about?

Does camper have any learning differences?

Here is more space to add addition information about camper's special needs

Parent/Guardian /Staff Authorization: This health history is correct and complete as far as I know, and the person herein described has permission to participate in all camp activities except as noted. I hereby give permission to the medical personnel selected by the camp director to order x-rays, routine tests, treatment, to release any records necessary for insurance purposes; and to provide or arrange related transportation for me/or my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization for the person named above. This form may be photocopied for trips outside of camp.
 I have read and understood the following statement

Date