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CAMPER PERSONAL HEALTH AND MEDICAL RECORD

To be complete by Parent/Guardian.
 

FAMILY DETAILS:
  Camp Code:
  Camp Location:
  Camp Date:
  Name:
  Date of birth:
  Age:
  Sex: Male Female
  Name of personal physician:
  Personal Health Insurance Carrier:
  Policy Number:
  Name of parent/guardian:
  Home Phone:
  Work Phone:
  Cell Phone:
 

If person is not available in the event of an emergency,notify:
  Name:
  Relationship:
  Phone:
  Name:
  Relationship:
  Phone:
  Check all items that apply,past or present, to camper's health history. Explain any 'Yes' answers
  Allergies: Food,medicines,insects,plants Yes No Explain
  General Information:
  Asthma: Yes No
  Attention Disorder deficiency: Yes No
  Cancer/Leukemia: Yes No
  Convulsions/Seizures Yes No
  Eyes/Ears/Nose/Throat Yes No
  Diabetes: Yes No
  Heart Trouble: Yes No
  Hemophilia: Yes No
  High Blood Pressure: Yes No
  Kidney Disease: Yes No
  Lungs: Yes No
  Mental Illness: Yes No
  Digestion: Yes No
  Takes Prescriptions Dailly: Yes No
  Explain:
  List any medications to be taken at camp:
  List any physical or behavioral conditions that mat affect or limit full participation in any day camp activities:
 

All medications must be checked in with the camp or program coordinator/ health director. Parent or guardian must complete in full and sign the "auhorization to administer medication to a camper" document(see separate sheet). This includes both prescription and over the counter medications
  Immunizations: (Give date of last inoculation)
  Tetanus Toxoid:
  Measles:
  Polio:
  Diphtheria:
  Mumps:
  Hepatitis B:
  Rubella:
  Pertussis:
 

In case of emergency, I understans every effort will be made to contact me. In the event I cannot be reached, I hereby give permission to the physician selected by the adult program coordinator in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child.
  Date:
  Signature of Parent/Guardian or Adult: