Camper/Volunteer Name *

First Name

Last Name

This form pertains to a

Camper

Adult Volunteer

Date of Birth *

MM

DD

YYYY

Parent/Guardian

For camper

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Doctor's Name *

First Name

Last Name

Dr. Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Chronic or Recurring Illness

Please check all that apply

Ear infection

Bleeding/clotting disorders

Hypertension

Asthma

Heart defect/disease

Musculoskeletal disorders

Seizures

Diabetes

Date of last health examination

MM

DD

YYYY

Is participant under a doctor/psychologist care now

Yes

No

Since last health exam, has participant had:

check those that apply

A serious injury requiring medical attention

Any prescribed or over the counter medications

Treatment in a hospital or emergency room

Any restrictions concerning physical activity

An illness lasting more than five days

A surgical procedure or fracture

Any exposure to a contagious disease

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)

Yes

No

Check those that apply

Bedwetting

Constipation

Menstrual l cramps

Motion sickness

Nosebleeds

Sleep disturbances

Emotional disturbances

Fainting

Hearing impairment

Sickle cell trait or disease

Special diet regime

Wear glasses or contact lens

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

Oral Polio

MM

DD

YYYY

Tuberculin test

MM

DD

YYYY

Today's Date *

MM

DD

YYYY