Medical Waiver/release Form Page 3
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3Participant’s Medical Profile and History
Please check this box if additional information is attached to this form.
Generally, my child’s health is: (check One) _____ Excellent
_____ Good
_____ Fair
_____ Poor
If Fair or Poor, please explain why: ____________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Check the following conditions or diseases your child has had or currently has:
_____ ADD/ADHD
_____ Anemia
_____ Anxiety Attacks
_____ Appendicitis
_____ Asthma
_____Bronchitis
_____ Chickenpox
_____ Chronic Headaches
_____ Diabetes
_____ Diagnosed Phobias
_____ Dizziness/Fainting
_____ Epilepsy
_____ Gi/Stomach Disorder
_____ Hay Fever
_____ Heart Disorder
_____ Hyperglycemia
_____ Hypoglycemia
_____ Hypertension
_____ Hypotension
_____ Influenza
_____ Kidney Disorder
_____ Measles
_____ Meningitis
_____ Migraines
_____ Mumps
_____ Pneumonia
_____ Pleurisy
_____ Polio
_____ Sinusitis
_____ Tetanus
_____ Thyroid Disorder
_____ Tuberculosis
**Please list any prescribed medication(s) your child will be taking while at camp. Medication sent to Impact must be in the
original prescription bottle and MUST be turned in to the nurse.
(Please send only what is needed for the week of camp. Medication will
only be administered to the person for whom the prescription designates.)
_________________________________________________________________________________________
**Please list any “rescue medications” (i.e. inhalers, epi-pens, nasal sprays, eye drops, etc.) your child will be bringing to camp
that he/she will be keeping to self-administer.
_________________________________________________________________________________________
**Please list all allergies that your child may have. These may include allergies to certain food, medication, insect bites or stings,
pollen, plants, or animals.
_________________________________________________________________________________________
Are there any other conditions or diseases that your child currently has or for which your child is receiving treatment? These may
include psychological conditions as well as physical conditions. If so, please specify the condition and the treatment, if any, your
child is receiving.
_________________________________________________________________________________________
Please describe any other special medical needs or conditions that your child may have. These may include significant hearing,
sight or speech impairments, various physical disabilities, restricted diets, etc.
_________________________________________________________________________________________
Please list any major operations your child has had and give the approximate date of the surgery.
_________________________________________________________________________________________
Notice: Youth Ministries regularly photographs and videotapes during our events. If you do not want your image to be used by
the Youth Ministries Office in video presentations, publications, promotions, on our web site or in any other manner, please
contact our office and every effort will be made to assure that your image will not be used.
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