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Health Form
Health History Form
Parent portion of health form
Camper's Legal Name
(Required)
First
Middle
Last
(Required)
Male
Female
Birth Date
(Required)
Month
Day
Year
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Parent/guardian with legal custody to be contacted in case of illness or injury:
(Required)
First
Last
Relationship to camper
(Required)
Phone
(Required)
Email
(Required)
Address (if different from camper)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Second parent/guardian or other emergency contact:
Name
(Required)
First
Last
Relationship to Camper:
(Required)
Phone
(Required)
Email
Additional contact in event parent(s)/guardian(s) can not be reached:
Name
First
Last
Relationship to camper:
Phone
Email
Medical Insurance Information
Is this camper covered by family medical/hospital insurance?
Yes
No
General Health History
Check "Yes" or "No" for each statement.
Has/does the camper:
Ever had surgery?
(Required)
Yes
No
Ever been hospitalized?
(Required)
Yes
No
Have recurrent/chronic illnesses?
(Required)
Yes
No
Had a recent infectious disease?
(Required)
Yes
No
Had asthma/wheezing/shortness of breath
(Required)
Yes
No
Had a recent injury?
(Required)
Yes
No
Have diabetes?
(Required)
Yes
No
Had seizures?
(Required)
Yes
No
Had headaches?
(Required)
Yes
No
Wear glasses or contacts?
(Required)
Yes
No
Had fainting or dizziness?
(Required)
Yes
No
Passed out/had chest pain during exercise
(Required)
Yes
No
Had mononucleosis during the past year?
(Required)
Yes
No
Have problems with falling asleep?
(Required)
Yes
No
If female, have menstruation problems?
(Required)
Yes
No
Have history of sleepwalking?
(Required)
Yes
No
Ever had back/joint problems?
(Required)
Yes
No
Have a history of bedwetting?
(Required)
Yes
No
Have problems with diarrhea/constipation
(Required)
Yes
No
Have any skin problems?
(Required)
Yes
No
Traveled outside the country in the past 9 months?
(Required)
Yes
No
Please explain "Yes" answers in the space below.
For travel outside of the country, please name countries visited and travel dates.
Mental, Emotional, and Social Health:
Check "Yes" or "No" for each statement.
Has the camper:
Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperctivity disorder (AD/HD)?
(Required)
Yes
No
Ever been treated for emotional or behavioral difficulties or an eating disorder?
(Required)
Yes
No
During the past 12 months, seen a professional to address mental/emotional health concerns?
(Required)
Yes
No
Had a significant life event that continues to effect the camper's life?
(Required)
Yes
No
(History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others?)
Please explain "yes" answers in the space below.
The camp may contact your for additional information.
Medications
"Medication" is any substance a person takes to maintain and/or improve their health. This INCLUDES vitamins & natural remedies. The camp requires original pharmacy containers with labels which show the camper's name and how the medication should be given. Parents need to provide enough of each medication to last the entire time the camper will be at camp.
Does your camper take any prescription or OTC medications?
(Required)
Yes
No
If so a MD/NP/PA must write a prescription!
Medications given at BREAKFAST
Name of Medication
Dose
Add
Remove
Name of medication
Amount or dose given
How is it given?
When is it given?
Breakfast
Lunch
Dinner
Bedtime
Reason for taking it?
Date sarted
MM slash DD slash YYYY
Do you need to enter an additional medication?
Yes
No
Name of medication
Amount or dose given
How is it given?
When is it given?
Breakfast
Lunch
Dinner
Bedtime
Reason for taking it?
Date started
MM slash DD slash YYYY
Do you need to enter an additional medication (2)
Yes
No
Name of medication
Amount or dose given
How is it given?
When is it given?
Breakfast
Lunch
Dinner
Bedtime
Reason for taking it?
Date started
MM slash DD slash YYYY
Do you need to enter an additional medication (3)
Yes
No
Name of medication
Amount or dose given
How is it given?
When is it given?
Breakfast
Lunch
Dinner
Bedtime
Reason for taking it?
Date started
MM slash DD slash YYYY
Non-Prescription medications (only click on an item if it SHOULD NOT be given)
Acetaminophen (Tylenol)
Aloe
Ammonia inhalent (for fainting)
Bacitracin ointment
Bactroban 2% ointment (Mupirocin - for skin infection)
Benzocaine gel (Orasol, Anbesol - for toothaches)
Calamine lotion
Calcium Carbonate (Tums, antacid)
Cetirizine (Zyrtec - antihistamine)
Dextromethorphan (Robutussin DM, Delsym - cough syrup)
Diphenhydramine (Benadryl - antihistamine)
Epinepherine (Epipen - for anaphylaxis)
Generic cough drops
Gualfenesin (Robutussin - cough syrup)
Hydrocortisone 1% cream
Ibuprofen (Advil, Motrin)
Lidocaine Gel (pain relieving burn gel)
Loperamide (Immodium AD - antidiarrheal)
Loratadine (Claritin - antihistamine)
Milk of Magnesia (laxative)
Phenol spray (Chloraseptic - sore throat spray)
Phenylephrine (Sudafed PE - decongestant)
Pseudophedrine (Sudafed - decongestant)
Tolnaftate 1% cream (anti fungal)
These non-prescription medications are commonly stocked in camp health Centers and are used on an as-needed basis to manage illness and injury. Please click on any medication the camper SHOULD NOT be given.
Allergies and Asthma
Does the camper have Asthma?
(Required)
Yes
No
Does the camper need to carry an inhaler with them?
Yes
No
Another form needs to be filled out by a doctor if the camper has permission to self-administer an inhaler.
Does the camper have food allergies?
(Required)
Yes
No
Please list food allergies
Does the camper have allergies to any medications?
(Required)
Yes
No
Please list medication allergies
Does the camper have allergies to the environment (insect stings, hay fever, etc)
(Required)
Yes
No
Please list environmental allergies
Does the camper have any other allergies that aren't previously listed?
(Required)
Yes
No
Please list other allergies
Does the camper need to carry an epi-pen
Yes
No
Another form needs to be filled out by a doctor if the camper should self administer an epidural-pen.
Please describe allergic reactions.
Parent/Guardian Authorization for Health Care:
Consent
(Required)
I agree to the authorization for Health Care
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by th camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. in addition, the camp has permission to obtain a copy of my child's health record from providers who treat my child and these providers may talk with the program's staff about my child's health status.
Parent signature
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