Summer Camp Health Form

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Summer Camp
Health Form
Camp Name/Date(s):____________________________________________________
The health form is kept confidential and used by our health services staff (or emergency
medical personnel). Every camper needs a completed health form to participate in any
summer camp programs. Please fill out this form as completely as possible. Thank
you!
S
I – B
C
I
ECTION
ASIC
ONTACT
NFORMATION
Camper Name___________________________________________________________________________
LAST
FIRST
MIDDLE
Birth date_______/_______/_______ Age ________
Gender
Male
Female
Home Address__________________________________________________________________________
STREET
CITY
STATE
ZIP
Home Phone_____________________________________
Parent/Guardian #1 Name________________________________________________________________
Relationship:_______________________________
Day Phone__________________________
Night Phone__________________________
Day Phone is
Home
Work
Cell
Night Phone is Home
Work Cell
Parent/Guardian #2 Name_________________________________________________________________
Relationship:_______________________________
Day Phone__________________________
Night Phone__________________________
Day Phone is
Home
Work
Cell
Night Phone is Home
Work Cell
Additional Emergency Contact_____________________________
Relationship_______________
(In case we can’t reach YOU)
Day Phone__________________________
Night Phone__________________________
Day Phone is
Home
Work
Cell
Night Phone is Home
Work Cell
Family Physician Name_________________________________
Phone_______________________
Dentist/Orthodontist Name_____________________________
Phone_______________________
S
II – I
I
ECTION
NSURANCE
NFORMATION
Is the camper covered by family medical/hospital insurance?
Yes No
If yes, indicate Insurance Carrier_____________________________________
Group #________________________ Policy #__________________________
Policy Holder’s Name__________________________________ Relationship to participant_____________
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Parent category: Medical
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