HealthForm2020 .pdf

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Original filename: HealthForm2020.pdf
Title: EAST OHIO CAMPS
Author: Director

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EAST OHIO CAMPS
EMERGENCY MEDICAL FORM

PLEASE BRING TO CAMP
DO NOT MAIL

(to be completed by Legal Guardian)

CAMPER’S INFORMATION: (Please Print)
NAME:

DOB:

ADDRESS:

PHONE # (

CITY:

STATE:

/

/

AGE:
)

-

ZIP:

PARENT/LEGAL GUARDIAN CONTACT INFORMATION:

(Please Print)

FIRST CONTACT
DAY PHONE # (

NAME:
LAST

FIRST

DAY PHONE # (

NAME:
LAST

FIRST

)

LAST

FIRST

)

-

)

-

)

-

EVENING PHONE #(
MOBILE PHONE #(

RELATIONSHIP TO CAMPER:

-

)

EVENING PHONE #(

DAY PHONE # (

NAME:

-

)

MOBILE PHONE #(

RELATIONSHIP TO CAMPER:
THIRD CONTACT

-

EVENING PHONE #(
MOBILE PHONE #(

RELATIONSHIP TO CAMPER:
SECOND CONTACT

INSURANCE INFORMATION:

)

)
)

-

(Please Print)

PLEASE FILL OUT INFORMATION BELOW OR ATTACH A COPY OF THE FRONT AND BACK OF THE INSURANCE CARD. ALSO,
IF YOU HAVE A PRESCRIPTION CARD, PLEASE ATTACH A COPY OF FRONT AND BACK.

INSURANCE HOLDER’S PERSONAL INFORMATION

NAME
DOB __/__/____
ADDRESS (IF DIFFERENT THAN CAMPERS)

ADDRESS
CITY
STATE
ZIP
EMPLOYER
PARENT/GUARDIAN AUTHORIZATIONS:

INSURANCE COMPANY INFORMATION

COMPANY
ADDRESS
CITY
ZIP
INS. CO. PHONE #
GROUP #
ID #

STATE

I am/we are in favor of the above person attending camp and participating in all activities unless otherwise specified. As
parent(s) or legal guardian(s) we accept the conditions stated, including the release of the Conference and Camp
Management/staff from liability in case of accident/injury.
I give permission for my child to participate in off-site travel, under the supervision of the camp staff, as is part of the
program for the summer camping event for which she/he is registered. I authorize the use of photographs or video in
promotional materials.
I agree to the release of any records necessary for treatment, referral, billing or insurance purposes for the camper
named on this health form. IN CASE OF MEDICAL ILLNESS OR INJURY, I hereby give permission to the camp to obtain
proper medical care for the camper named on this health form. I authorize the camp nurse or certified first aid care
provider to give first aid care, medicine, or treatment as ordered by the camp physician. IN CASE OF MEDICAL
EMERGENCY or in the event that the named camper needs medical care beyond camp facilities, I/we understand that
every effort to reach the parent(s), guardian(s) or friend listed will be made. If no one can be reached, I/we hereby give
permission to the attending physician to hospitalize, secure proper treatment for, order injection, anesthesia or surgery as
necessary for the camper named on this health form.
Signature:____________________________________Date:_______________




Name:
Age:

HEALTH FORM (Please photocopy and create one form for each camper)
Event #:
Height:
Weight:
❑ Male

Does the camper have any of the following conditions:
❑ ADD ❑ADHD ❑ODD ❑Behavior Problems
❑ Anemia currently
❑ Asthma ❑ other Lung Disease
❑ Bed Wetting ❑ Frequent Urinary Infections
❑ Diabetes
❑ Ear Infections ❑ Tubes in Ears Currently
❑ Eating Disorders ❑ Anorexia/Bulimia ❑ Obesity
❑ Epilepsy ❑ Absence Spells ❑ Grand Mal Seizures
❑ Hay Fever/Seasonal Allergies
❑ Hypertension ❑ Heart Disease
❑ Mental Health Concerns ❑ Anxiety Disorder
❑ Depression ❑ Bipolar Disorder
❑ Menstrual Concerns LMP prior to camp __/__/__
❑ Sleep Walking ❑ Sleep Talking
❑ Sprains, Strains, Muscle, Bone or Joint Problems
❑ Stomach problems ❑ Diarrhea ❑Constipation
❑ Other diagnosis or concerns:___________________
_____________________________________________
Explain conditions checked above including required
medications, treatments, special restrictions or
considerations while at camp: ____________________
_____________________________________________
_____________________________________________
_____________________________________________

❑ Female

Surgeries/Serious Injuries/Broken Bones
Please List with Date:
❑ None
__________________________________
__________________________________

Allergies:
❑ None Known
❑ Insect/Bee Stings
❑ Serious/Life threatening reaction
❑ Localized swelling or redness at site
❑ Medication Allergies
❑ Serious/Life threatening reaction
❑ Hives, rash, diarrhea, other
Please list Med Allergies:______________
__________________________________
__________________________________

❑ Food Allergies
❑ Serious/Life threatening reaction
❑ Cramps, diarrhea, hives
Please list Food Allergies:_____________
__________________________________
__________________________________
❑ Other Allergies: ___________________
_____________________________________
_____________________________________

❑ Carries Epi Pen
❑ Carries Emergency Inhaler

IMMUNIZATION HISTORY:
Date (month/year) of your most recent tetanus immunization: ______________________________________
Has this camper completed the immunizations that were required for school attendance?

❑ Yes ❑ No

CURRENT MEDICATIONS AND INHALERS: (both prescribed and over-the-counter - add additional page if needed)
Drug Name
Dosage
Time of day to be administered
Reason for Medication

List any special dietary concerns or restrictions at camp:_____________________________________________
_________________________________________________________________________________________
Has the camper been exposed to a communicable disease in the last 21 days?
❑ Yes ❑ No
If yes, what?____________________________ when?____________________________________________
Name of Camper’s Physician:____________________________________Telephone:____________________
Restrictions:
❑ I have reviewed the program and activities of the camp and feel the camper can participate without restrictions.
❑ I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions
or adaptations: ___________________________________________________________________________________
__________________________________________________________________________________________________

Parent’s Signature: ________________________________________________Date:___________________
OFFICE USE ONLY ❑ Health Check

❑ Information Verified ❑ Meds Collected

Initials:


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