Camper Information

To be completed by Parent

Alergies *

Medication: All medications given during day camp MUST be in pharmacy containers and appropriately labeled

Medication *
Do you plan on taking your child off  their medication this summer *

IMPORTANT - This authorization for Health Care MUST be completed by Parent/Guardian

To the best of my knowledge this health form is correct and the person described is in good health.  My child has my permission to engage in all camp activities except as noted.  In case of emergency, if parents or emergency contact can’t be notified, I hereby give permission to the medical personnel and/or hospital selected by the Camp Director to secure proper treatment for my child as named above; release any records necessary for insurance purposes; and to provide or arrange necessary transportation.  I understand the information on this form will be shared on a ‘need to know’ basis with camp staff.  This completed form may be photocopied for trips out of camp.

I have disclosed all pertinent medical information including information regarding prescription medications.   I hereby give permission to allow my child’s physician to give Camp Chabad medical information about my child, should it be required by the camp.


Health History - Please check all that apply and explain below all that are checked (write # next to explanation)

Did your child ever have or currently
has any of the following

Immunization: (ACA requirement)

Are all required school immunizations up to date? *
Date of last Tetanus Booster

Mental and Emotional Health:

Mental and Emotional Health: (Explain ‘yes’ answers below)
Attention Deficit Disorder (ADD) or ADHD
A psychiatric diagnosis such as depression, OCD,
An emotional health concern
A learning disability
Seen or is currently seeing a professional to address mental/emotional health concerns