Campers Health History printable pdf download

Campers Health History

Camper’s Name _______________________________________________________

Home Phone _____________________________________ Age _______________

Address _____________________________________________________________

City ___________________________ State ______________ Zip ______________

To THe ParenT: THis form sHould be ComPleTed as aCCuraTely as Possible

by a ParenT or guardian. bring THis form wiTH you To CamP.

List any allergies camper may have to food, pollens or antibiotics. _______________________________________________

_____________________________________________________________________________________________________

Do you know of any physical disorder that would prevent this camper from participating in a vigorous camping program?

_____________________________________________________________________________________________________

Does he / she have a tendency to wet the bed regularly? _______________________________________________________

Does he / she ever walk in his or her sleep? __________________________________________________________________

Has he / she been given tetanus injections or boosters recently? _________ If so, when?_____________________________

Has his / her appendix been removed? _____________________________________________________________________

Are there any medications or treatments your child is currently taking of which we should be aware or which you will want

us to supervise during his or her stay at camp?

_____________________________________________________________________________________________________

Do you know specifically if your camper is allergic to bee stings, penicillin, animal (horse, dog, cat, etc.) etc.? ___________

_____________________________________________________________________________________________________

In case of emergency where you cannot be reached, is there some other close relation or party whom we might contact?

________________________________________________________ Phone No. ___________________________________

This child will participate in a program of vigorous camping activities including swimming, horseback riding, climbing,

jumping, hiking, etc. Please state, if in your opinion, this child is in physical condition to take part in such a program of

strenuous outdoor activities, and if not, what specifically should be avoided:

_____________________________________________________________________________________________________

Any additional remarks: _________________________________________________________________________________

e have two excellent, well-staffed clinics in Nashville. We’ll use these facilities in the event of any mi-

a noTe To ParenTs: w

nor scrapes or aches, etc. Bloomington and Columbus Hospitals are each about 30 minutes from Camp, should we need addi-

tional care. We will notify you if your child has gone to a doctor for any reason. The Camp has medical insurance to help cover

expenses here, but this insurance has limits and you may need to cover a minimal deductible amount if your child does need to

see a doctor. Should any fees exceed our Camp coverage limits, your own family policy would need to kick in here. Please sign

and date to indicate this arrangement is agreeable with you. Also indicate your insurance carrier and policy number.

Parent / Guardian Signature ___________________________________________________ Date ______________________

Family Medical Insurance Carrier ___________________________________________ Policy # ______________________

Name of your Family Doctor ________________________________________ Doctor’s Phone # ______________________

Campers Health History