Camper Health Form printable pdf download

CAMP MACLEOD – CAMPER HEALTH FORM

Camper’s Name: _________________________________________________ Camp ______________________

Last

First

Middle Initial

Health Card Number: _______________________________________ Date of birth: DD / MM / YYYY

Contact Information

Parent/Guardian: __________________________________________

Relationship to camper ________________

Home Phone # ____________________________________________ Work Phone # _______________________

Home address: ________________________________________________________________________________

Other Emergency Contact: ________________________________

Relationship to camper ________________

Home Phone # _________________________________________

Work Phone # _______________________

Family Doctor: __________________________________________

Phone # ____________________________

Health Concerns (diet/allergies/chronic conditions or special considerations we should be aware of as we prepare for your

camper): _________________________________________________________________________________________

_________________________________________________________________________________________________

If your camper has had any other operations or serious injuries please explain: __________________________________

Please note: To care for your child to the best of our ability, please describe any

other physical, emotional or behavioral problems _______________________________________________________

Has your child been exposed to or suffered from any infectious disease during the three weeks prior to the first day of

camp? For example: Measles, Chicken Pox, Mumps, Tuberculosis, Whooping Cough, H1N1, Mononucleosis, etc.

Yes

If yes, please call the Camp Director before coming to camp.

Date of last immunizations: ________________________________________________________________________

My Daughter has been informed about menstruation: Yes or No

Does your camper receive any medication? Yes or

If yes, please explain:

Illness/condition

Medication

Dosage

Time of day given

All medication must be given to the Director in the original package from the pharmacy on opening day.

Recent changes in Family (death, illness, divorce, etc) ___________________________________________________

Please Note: Head Lice: Parents/guardians of children identified with head lice or nits will be notified by the Camp

Director and will be required to seek treatment for the child. It is recommended that other members of the household be

checked as well. The parent/guardian is required to pick up the child immediately and keep them at home until the

problem is cleared. Once the problem is cleared the child is welcome back.

Please Note: You and your doctor are responsible for the health of your camper; this form should clearly indicate their

health status. The camp staff will do their utmost to contact the family if an emergency arises; however, the signature on

this form signifies that permission is granted for camp staff to arrange for medical attention with a local doctor and for that

doctor to provide any necessary treatment and that having taken such precautions as in the discretion of Camp MacLeod

as are deemed advisable, Camp MacLeod shall not be held responsible for any accident or illness involving my child.

Signature of Parent/Guardian _____________________________________________ Date _____________________

All information in this form is confidential.

Camper Health Form

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