Summer Camp Health Form Page 3
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1
2
3S
VI – H
H
ECTION
EALTH
ISTORY
Please know that we value your privacy. Health History information is available only to the camp health
staff. The more information you provide, the better we can do our job. Thanks!
Has the camper have a history of or is prone to any of the following (Please check all that apply).
1. Recent injury, illness or
10. Hypertension
21. Fractures
infectious disease
11. Bleeding/Clotting Disorders
22. Frequent Headaches
2. Chronic or recurring illness
12. Diabetes
23. Head Injury
3. Asthma
13. Mononucleosis (in last 12
24. Eating Disorder
4. Homesickness
months)
25. Diarrhea or constipation
5. Frequent Ear Infections
14. Chicken Pox
26Frequent Stomachaches
6. Seizure Disorder or Convulsions
15. Measles
27Wears glasses or contacts
7. Dizziness during or after
16. German Measles
28Been Hospitalized
exercise
17. Mumps
29Wears a Medic Alert ID
8. Chest pain during or after
18. Tuberculosis
exercise
19. Hepatitis
9. Heart Defect/Disease
20. Joint problems (knees, ankles)
Please list the number and provide explanation for any checked items
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Date of Last Physical Exam (Recommended within 24 months of camp)_____________
Physical Activities to be Limited or Restricted while at Camp
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
S
VII – A
ECTION
UTHORIZATION
My child has permission to engage in all prescribed camp activities except as noted. The information
provided on this form is accurate to the best of my knowledge. I have indicated any special health
conditions, including required medication and activity limitations which should be known to the
camp staff and medical personnel. I am aware of and accept the risk inherent in the program activity. I
give consent in advance for medical treatment at an appropriate facility in case of illness or injury.
Signature of Parent or Guardian X___________________________________ Date___________________
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