Camp Health Screening Form printable pdf download

Mountain Meadows Bible Camp

Health Screening Form

(Required for all attendees staying over 72 hours)

By state and county regulations, the Health Screening Form must be completed for each attendee

(camper and leaders). Each person needs to be screened by a qualified person (doctor, nurse, EMT etc.)

within 24 hours of arrival to camp.

Camper or Counselor Name________________________________________ Camp Dates______________

Gender: M / F

Church or Group Name ______________________________________________________

Name of Emergency Contact _________________________________ Relationship_____________________

Phone Number of Emergency Contact (home)

(cell)___________________________

Health Questions

1. In the last week, have you had and nausea, vomiting, and/or diarrhea with a fever?

If YES, describe: ______________________________________________________________

___________________________________________________________________________

2. In the last week, have you had a cough, congestion, and/or sore throat with a fever or a rash?

If YES, describe: ______________________________________________________________

___________________________________________________________________________

3. Has anyone in your family had the flu this past week?

4. Do you have any open sores or rashes that need to be treated?

If YES, describe: ______________________________________________________________

___________________________________________________________________________

5. Do you have an ear infection or eye infection that needs medication?

If YES, describe: ______________________________________________________________

___________________________________________________________________________

6. Have you had the Chicken Pox disease or the Chicken pox vaccine (Varicella)?

7. Have you had any recent injuries that involved a casted fracture, head injury (concussion),

or wound that required staples that need to be removed while at camp?

If YES*, describe: ______________________________________________________________

___________________________________________________________________________

*If YES to #7, you must be cleared by a doctor in order to participate in camp activities.

8. Did you bring any medication with you to camp? (If under 18 years old or staying in a cabin

with kids, all medications must be locked and administered by qualified staff). Please fill out

and submit Medication Administration Record (MAR) with medications.

Signature of Health Screener ___________________________________________ Date________________

Camp Health Screening Form