CAMP HEALTH QUESTIONNAIRE

Basic Contact Information
Camper Name *
Camper Name
Birthday *
Birthday
Home Address *
Home Address
Home Phone *
Home Phone
Parent/Guardian #1 Name *
Parent/Guardian #1 Name
Cell Phone *
Cell Phone
Other Phone
Other Phone
Insurance Information
Is the camper covered by family medical/hospital insurance? *
Policy Holder's Name
Policy Holder's Name
Medications
Will the camper be taking medications while at camp?
Allergies
Does the camper have any allergies?
If yes, the camper is allergic to:
Immunizations
Is the camper up to date on their immunizations?
Health History
Please know that we value your privacy. Health history information is available only to the Program Director/Health Officer.
Has the camper had/have a history of or is prone to any of the following:
Date of last physical exam
Date of last physical exam
Authorization
My child has permission to engage in all prescribed camp activities except as noted. The information provided on this form is accurate to the best of my knowledge. I have indicated any special health conditions, including required medication and activity limitations which should be known to the camp staff and medical personnel. I am aware of and accept the risk inherent in the camp activities. I give consent in advance for medical treatment at the appropriate facility in the case of illness or injury.
By typing your name in the box below and submitting this form, you are agreeing to the content of this form.