2012 Registration Packet - Health Form

MEDICAL INFORMATION FOR CAMPER:  (Name)_________________________________

ALLERGIES: ___________________________________________________________________

Note to Parents:  We strongly advise that you have INDIVIDUAL HEALTH INSURANCE to protect your child.  Every precaution will be taken to ensure your child's stay with us is a fun and safe experience.  In the event of an accident, you will be notified immediately.  Please fill out the following Health Form completely and accurately as reference for our nursing staff.

Hospitalization/Insurance Company__________________________________________________

Group or Policy No._______________________________________________________________ (A copy of health insurance card (front & back) is required with application.)

Doctor's Name___________________________________________ Phone___________________

Please list any medication that your child will bring to camp:

(Include prescription and non-prescription medications such as aspirin, vitamins, etc)

Medication__________________    Dosage___________________    Reason__________________

Medication__________________    Dosage___________________    Reason__________________

Medication__________________    Dosage___________________    Reason__________________

Medication__________________    Dosage___________________    Reason__________________

Does your child have seizures?  YES____    NO____     If yes, most recent occurrence___________

Medication for seizures______________   Dosage___________ Special precautions_____________

Has your child ever been knocked unconscious or passed out?   YES____     NO____

If yes, when and how?______________________________________________________________

The date your child last saw a physician____________ Physician's name_____________________

Reason for the visit________________________________________________________________

Year of last Tetanus shot_____________

Does your child have a history of: Heart Problems? YES____ NO____  Diabetes? YES___   NO__

List any other helpful medical information that will assist in the management of your child's safety:

________________________________________________________________________________

HEALTH RELEASE

This health release must be signed by a parent or legal guardian & sent with registration.

This health history is correct as far as I know.  In case I cannot be reached, I hereby give permission to medical personnel with proper credentials to give emergency treatment to:

Camper's Name_______________________________________ SS#________________________

Signed__________________________________________________________________________

                                                                 Legal guardian of minor child