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Camper Medical Information

This form only needs to be completed once per camper per year. 

Please use the same email address associated with your account.

Allergies:

This camper is allergic to:
(Put N/A if camper has no known allergies)

Diet, Nutrition:

Diet, Nutrition:

Restrictions:

Restrictions:

Medical Insurance Information:

This camper is covered by family medical/hospital insurance
Drag & Drop Files, Choose Files to Upload
Drag & Drop Files, Choose Files to Upload

Immunization History:

Provide the month and year for each immunization. Starred (*) immunization must be current.
List ALL Doses with Month/Year
List ALL Doses with Month/Year
List ALL Doses with Month/Year
List ALL Doses with Month/Year
List ALL Doses with Month/Year
List ALL Doses with Month/Year
List ALL Doses with Month/Year
List ALL Doses with Month/Year
Had Varicella (chicken pox)
List ALL Doses with Month/Year if Yes
List ALL Doses with Month/Year
Date with Negative or Positive result
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If your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being fully immunized. 

Clear Signature

Medication:

"Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Many states require original pharmacy containers with labels which show the camper's name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp.
Medication:
List Time To Be Taken (Breakfast / Lunch / Dinner / Bedtime)
The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Please select the medications the camper should not be given.

General Health History: Check Yes or No for each statement. Explain "Yes" answers below.

Ever been hospitalized
Ever had surgery
Have recurrent/chronic illness
Had a recent infectious disease
Had a recent injury
Had asthma/wheezing/shortness of breath
Have diabetes
Had headaches
Had seizures
Wear glasses, contacts, or protective eyewear
Had fainting or dizziness
Passed out/had chest pain during exercise
Had mononuleosis ("mono") during the past 12 months
If female, have problems with periods/menstruation
Have problems with falling asleep/sleepwalking
Ever had back/joint problems
Have a history of bedwetting
Have problems with diarrhea/constipation
Have any skin problems
Traveled outside the country in past 9 months

Mental, Emotional, and Social Health: Check "Yes" or "No" for each statement.

Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)
Ever been treated for emotional or behavioral difficulties or an eating disorder
During the past 12 months, seen a professional to address mental/emotional health concerns
Had a significant life event that continues to affect the camper's life ( History of abuse,death of a loved one, family change . adoption, foster care, new sibling, Survived a disaster, others)

Health-Care Providers:

What Have We Forgotten to Ask?

Permission to Treat Authorization

I hereby give permission to the medical personnel to provide routine health care; to administer prescribed medications; and to administer emergency treatment for me/my child, including, but not limited to X-rays, routine tests and treatment and/or hospitalization; and to provide or arrange necessary related transportation for me/my child. I also agree to the release of any records necessary for treatment, referral, billing or insurance purposes.

If the person named herin is a minor, it is my intention that representatives of the camp be considered "personal representatives" for the purpose of disclosing health information that is protected under the Health Insurance Portability and Accountability Act of 1996. I also agree to the disclosure to camp representatives of protected health information of the person named herein in order to provide information related to the person's ability to participate in camp activities; and if the person named herein is a minor, to to provide information to the camp representatives to keep me informed of my child's health situation.

In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, inclulding hospitalization, for the named person. This completed form may be photocopied for trips out of camp.

Camper Agreement

I understand and agree to abide by any restrictions placed on my activity at camp.

Clear Signature