Camper/Volunteer Name
*
First Name
Last Name
This form pertains to a
Date of Birth
*
MM
DD
YYYY
Caregiver/Guardian
For camper
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
Doctor's Name
*
First Name
Last Name
Dr. Phone
*
(###)
###
####
Emergency Contact
*
First Name
Last Name
Relationship
Emergency Contact Phone
*
(###)
###
####
Severe/Life-Threatening Health Conditions
Please describe any severe or life-threatening health conditions the participant has, and list any medications prescribed to manage the health condition
Chronic or Recurring Illness
Please check all that apply
Other:
Date of last health examination
MM
DD
YYYY
Is participant under a doctor/psychologist care now
Were any complicating medical problems noted in the last health exam?
Since last health exam, has participant had:
check those that apply
IF YOU MARKED ANY ABOVE, PLEASE EXPLAIN, INCLUDING DATES:
Will participant need to take medication while at camp?
This includes inhalers and EpiPens. If camper requires medication at camp, you will need to complete the Medical Provider Permission for Medication form. Volunteers cannot administer medications without parent/doctor permissions. (If yes, you will receive the from via e-mail)
Anaphylactic Reactions
If the participant has an allergy that causes an anaphylactic (life-threatening) reaction, list them here. Include information on any emergency medications prescribed in case of an allergic reaction, and when the last time the participant received emergency medications or care for a a reaction.
Animals
Pollen
Meds/Drugs
Plants
Hay fever
Food
Insect stings
Other (specify)
Check those that apply
Other (please specify)
Further Explanations of Above Items
Please explain any items that are checked. Indicate any information useful to the adult in charge in relation to ANY of these health conditions. Indicate any activities to be encouraged or restricted, and include any dietary restrictions.
D.P.T
Diphtheria, Pertussis, Tetanus
MM
DD
YYYY
Tetanus/Dip booster
MM
DD
YYYY
Measles
MM
DD
YYYY
Mumps
MM
DD
YYYY
Rubella
MM
DD
YYYY
Tuberculin test
MM
DD
YYYY
State of Washington Vaccination Standards
*
Is the participant fully vaccinated with all vaccines required by the state of Washington to participate in childcare or school?
Other immunization information
Today's Date
*
MM
DD
YYYY
Today's Date
*
MM
DD
YYYY
