Camp Health Record Form

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Shrine Mont Camps 2015: Health Record
Dear Parent/Guardian:
The following information is required to meet the physical, intellectual, and emotional needs
of the camper. No camper will be admitted to camp without this form, and all forms should be
submitted as early as possible. A camp nurse will review your form and will call you with any
questions or to discuss a treatment plan.
A physical examination OR a physician’s signature on this form is required for
attendance at camp. The standard Virginia School entrance form is available on the “Forms” page of
our website for your convenience but you may substitute another physical if you desire, as long as it
is dated within 15 months of the starting date of camp. Please mark your camper’s name/session on
every page.
Camp and Session: _____________________________________________________________________________________________
Camper’s Name: Last__________________________ First__________________________ Middle_________________________
Male Female Date of birth:______________________________________________________________________________
Address: _________________________________________________________________________________________________________
Parent/Guardian’s Name (1): __________________________________________________________________________________
Address: _________________________________________________________________________________________________________
Phone (Home or Cell):____________________________________ Phone (Work): ____________________________________
Parent/Guardian’s Name (2): __________________________________________________________________________________
Address: _________________________________________________________________________________________________________
Phone (Home or Cell): ___________________________________ Phone (Work): _____________________________________
Emergency Contact: _____________________________________ Emergency Contact Phone: _______________________
Camper’s Social Security number: _____________________________________________________________________________
Family Health Insurance Co: ______________________________________ Contract #: ____________________
Plan Code:____________________ Group #:________________ Please attach a photocopy of Insurance Card.
PERMISSION TO PROVIDE NECESSARY TREATMENT/EMERGENCY PLAN
I give Shrine Mont Camps staff permission to administer prescription and over-the-
counter medications to my child as prescribed by a licensed physician.
I authorize medical personnel selected by the Director of Shrine Mont Camps to render
necessary first aid and medical care to my child. In an emergency, if I am unable to be
reached, I consent for Shrine Mont Camps to act on my behalf in granting permission for
medical treatment including surgery. I give permission to release medical information
regarding my child to Shrine Mont camps and to other health care providers or my
insurance company.
I have received a copy of the Federal HIPAA Privacy Policy for Shrine Mont Camps
Check the following: (Explain problem areas identified below on the back of this form)
Parent/Guardian signature: ________________________________________________ Date: ________________________
I agree to abide by the rules of the camp and any restrictions placed on my camp activities and will
Camper Name: ________________________________________________________________________________________________
endeavor to be a responsible and willing participant in the activities of the camp throughout the
entire session.
Camper Signature: ___________________________________________________________ Date: _______________________

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