HEALTH/MEDICAL FORM-

Back HEALTH/MEDICAL FORM-

INSTRUCTIONS TO PARENT OR GUARDIAN

1. Please answer ALL questions. Print in ink.

2. Complete and sign this form, it authorizes you or your child to participate in camp activities.

3. Make a copy for your files and keep it for least three years.

4. This form MUST BE brought to camp. Campers will not be allowed to attend without it.

CHURCH

/ /Camper / /Counselor / /Staff/Employee

Name______________________________________Birth Date__/__/__Age_____ Male or Female

Last First Middle

Parent or Guardian________________________________ Parent Social Security No._____________

Home Address____________________________________________________Phone (___)_________

Street & Number City State Zip

Business Address_________________________________________________Phone (___)_________

Street & Number City State Zip

2^nd Parent or Guardian______________________________ Parent Social Security No._____________

Home Address____________________________________________________Phone (___)_________

Street & Number City State Zip

Business Address_________________________________________________Phone (___)_________

Street & Number City State Zip

If parent or Guardian not available in an emergency. Notify:

Name ___________________________________________________________Phone (___)_________

Street & Number City State Zip

Insurance Information

Is the member (camper) covered by family health/medical/hospital insurance? Yes No

Health Insurance Carrier ______________________________________Group No._________________

Health Insurance Address ___________________________________________Phone (___)_________

Street & Number City State Zip

Name of Insured ________________________________Relationship to member (camper)___________

Physician_________________________________________________________Phone (___)_________

Street & Number City State Zip

Dentist___________________________________________________________Phone (___)_________

Street & Number City State Zip

Health History: (check appropriate box – giving approximate dates)

Illness or Diseases Date

Mo/Yr

r Frequent Ear Infections ________

r Heart Defect/Disease ________

r Convulsions ________

r Bleeding/Clotting Disorders ________

r Hypertension ________

r Mononucleosis ________

r Chicken Pox ________

r Measles ________

r German Measles ________

r Mumps ________

r Hepatitis ________

Allergies

List all known allergies including medication

Date

Mo/Yr

r Hay Fever ________

r Ivy Poisoning, Ect. ________

r Insect Stings ________

r Penicillin ________

r _______________ ________

Immunization History

Required immunizations must be determined locally. Please record the date (month and year) of basic immunizations and most recent booster doses:

Vaccines		Year of Basic Immunization	Year of Last Booster
Diphtheria Pertussis(Whooping Cought) Tetanus And/or	}DPT	1 2 3	1 2
Tetanus Diphtheria	}TD
Oral Polio (Sabin) TOPV And/or
Injectable Polio (Salk)
Measles(hard Measles, red Measles, Rubella) Mumps Rubella (German measles, 3-day measles	}MMR
Other
Tuberculin Test given ________(most recent)

The applicant is under the care of a physician for the following condition(s):________________________________________

Medication being taken (send instructions): Med #1________________ Dosage/Time ______________ Reason _____________

Medication being taken (send instructions): Med #2________________ Dosage/Time ______________ Reason _____________

Medication being taken (send instructions): Med #3________________ Dosage/Time ______________ Reason _____________

Medically prescribed meal plan or dietary restrictions:____________________________________________________________

Operations, serious injuries disabilities, chronic or recurring illnesses: _______________________________________________

Explanation of any reported loss of consciousness, convulsions, or concussion: _______________________________________

Does applicant have: epilepsy? \ \ Yes \ \ No diabetes? \ \ Yes \ \ No Asthma? \ \ Yes \ \ No

While at camp, can child be given the following over the counter (OTC) medication (please check ALL that child may be given) .

r Tylenol, 325 mg

r Tylenol, 500 mg

r Pepto Bismol

r Ibuprofen, 200mg

r Ibuprofen, 400mg

r OTC Cough Syrup

r Benadryl, 25mg

r Benadryl, 50mg

Additional Health Information: ______________________________________________________________________________

______________________________________________________________________________________________________

Parent or Guardian Signature _____________________________________________Phone __________________________

Address ________________________________________________________________________Phone (___)____________

Street & Number City State Zip

It is understood that all campers in attendance will abide by the rules of the camp regulations. If any member does not, the privileges of participating in the activities will be taken away, or in the case of a very serious violation, the member will be returned home.

This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted.

Emergency authorization: I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests and treatment for me as a volunteer, counselor, staff or employee, or my child in the event I cannot be reached in an emergency. I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for me or my child as named above.

Signature of parent or guardian or adult camper/staffer________________________________________Date______________