Minor Medical Release Form Page 2
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4Minor Medical History
Minor’s Current Health Condition: Excellent
Good
Poor
Contact Lenses:
Yes
No
List all medication sent with camper (note: all prescription medications must be in the original bottle with
the minor’s name typed on the label in order for the nurse to distribute medications)
Name of Medication
Dosage
Time(s) of Day
Medical Reason
*I authorize the medications listed above, to be dispensed by Camp of the Hills staff members.
Minor has ever had a history of:
Please check any and all that apply
____ Asthma
____ Hepatitis
____ Nervous Stomach
____ Broken Bones
____ Rheumatic Fever
____ Operation: (please Specify)
____ Congenital defect
____ Diabetes
__________________________
____ Seizures
____ Emotional Problems
___________________________
Please explain any special medical needs, please give details (i.e. asthma, diet restrictions, sunburns
easily, bed wetter, sleep walker, menstrual difficulties, hearing impairment, etc.):
____________________________________________________________________________________
____________________________________________________________________________________
Please explain all allergies and reactions (i.e. bug stings, food allergies, allergic reactions to any
medications, etc.): ____________________________________________________________________
____________________________________________________________________________________
Any problems requiring special attention (behavioral issues, mental disorders, developmental delays,
severe emotional trauma, etc.):
____________________________________________________________________________________
____________________________________________________________________________________
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