Camp Health Record Form Page 3
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4Camp Session: _________________________________________________________________________________________________
Please use the space below to explain anything you would like to have the camp staff know about
your child. This may include family issues, school problems, peer issues, etc. that may affect your
child at camp. The more we know about your camper, the more helpful we can be. Attach another
sheet if needed.
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Physician’s Signature: __________________________________________________ Date : ________________________________
(if physical not included)
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Below Reserved for Camp Nurse
Rescue inhaler: Y/ N
Expiration date: _____________________
Stored with:
Counselor
Camper
Infirmary
Epi-Pen: Y/ N
Expiration date: _____________________
Stored with:
Counselor
Camper
Infirmary
Allergies
Medications
Insects
Food Allergies
Eggs
Dairy
Peanuts
Tree nuts
Others
Medications to be administered at
AM
NOON
Dinner
PM
Other times: ________
Changes in meds Y/ N
New Health Condition Y/ N
Exposure to illness in 72 hours Y/ N
If yes, details:
Check-in Screening Date: _____________________
Nurse Initials:______________
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