Health Form - Camp Cowen
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1
2Camp Attending _______________________________________________________________________
Year _________________________
WEST VIRGINIA BAPTIST CAMP AT COWEN
PERMISSION FOR EMERGENCY TREATMENT & HEALTH HISTORY
Please fill out this form as completely as possible. Campers are not singled out, made to feel embarrassed or treated differently
because of information gathered from the health form. Rather, the more we know ahead of time, the easier it is to help your child
have a successful experience at camp. Thank you! Please mail or bring this form to camp on your day of arrival.
Every camper needs a completed health form to participate in any Cowen summer camp programs.
SECTION I – BASIC CONTACT INFORMATION
Name _______________________________________________________________ Birthdate ___________________ Age at Camp __________________
Last
First
Middle
Home Address ____________________________________________________________________________________________________________________
Street Address
City
State
Zipcode
Social Security Number of participant ______________________________________________________________ Gender:
M
F
Camper Lives With:
Mother & Father
Mother
Father
Grandparent
Other: ______________________________________________
Custodial Parent/Guardian _______________________________________________________________________ Phone __________________________
Home Address ____________________________________________________________________________________________________________________
(If different from above)
Street Address
City
State
Zipcode
Business Address _______________________________________________________________________________
Phone __________________________
Street Address
City
State
Zipcode
If not available in an emergency, notify ______________________________________________________________________________________________
Relationship ___________________________________________________________________________________ Phone __________________________
Address _________________________________________________________________________________________________________________________
Street Address
City
State
Zipcode
Family Physician Name ________________________________________________ Phone _____________________________________________________
Dentist/Orthodontist Name ____________________________________________ Phone _____________________________________________________
Parent/Guardian Authorizations: This health history is correct and complete as far as I know, and the person herein described has permission to
engage in all camp activities except as noted. I hereby give permission to the medical personnel selected by the camp director to order x-rays,
routine tests, treatment; to release any records necessary for insurance purposes and to provide or arrange necessary related transportation for me/or
my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer
treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out of camp. I understand that
all reasonable attempts will be made to contact me as soon as possible after the condition necessitating treatment arises, and, that failing to reach
me, all reasonable attempts to contact the alternate listed above will be made. I understand that all reasonable precautions will be taken for safety
at all times. I further release the West Virginia Baptist Convention, the Camp Cowen Board, the Parchment Valley Board of Directors, the West
Virginia American Baptist Youth, and all persons associated with these organizations from any liability associated with any accident, injury or disease
to the person who is the subject of this form.
SIGNATURE OF PARENT/GUARDIAN OR ADULT CAMPER/STAFFER___________________________________________________________
SECTION II – NOTARY
STATE OF WEST VIRGINIA
County of, __________________________________________________________ , ____________________________________________________ to wit:
I, a qualified Notary Public, in and for the County aforesaid, hereby certify that the person whose signature appears above, did on this date, appear
before me, after begin duly sworn or affirmed, and reading this document in its entirety did affix his or her signature hereto in my presence.
_________________________________________ NOTARY PUBLIC
Date Executed________________
My Commission Expires:________________Please imprint seal in the area to the right:
SECTION III – TRANSPORTATION
In order to protect your child, please provide us with the following information:
Who will be picking your child up at the West Virginia Baptist Camp at Cowen at the close of camp?
Name __________________________________________________________________________________________________________________________
Is there anyone in particular whom you do not want to pick your child up at the close of camp? If yes, please list the name(s) below:
Name __________________________________________________________________________________________________________________________
Name __________________________________________________________________________________________________________________________
THANK YOU FOR HELPING US PROTECT YOUR CHILD.
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