Health History & Medical Form

Camper Information

Child's First Name *

Child's Last Name *

Weeks attending camp *

Date of Birth *

Age in June *

Gender *

Home Address *

City *

State *

Zip *

Father's Name *

Home Phone *

Father's Work Phone *

Father's Cell *

Mother's Name *

Home Phone *

Mother's Work Phone *

Mother's Cell *

If not available in an emergency, notify *

Relationship *

Home Phone *

Work Phone *

Cell *

Custodial Parent/Guardian (if different than above) Name *

Phone *

Physician’s Name *

Physician’s Phone *

Dentist’s Name *

Dentist’s Phone *

Insurance Carrier or Plan *

Policy/Group # *

Insurance Co. Phone # *

SS# of policy holder or insurance ID # *

To be completed by Parent

Alergies *

Child has no known allergies

Child has an EpiPen? (If the child has an EpiPen at school, it MUST be at camp also)

Food allergy to

Insect stings or other substances

Medication allergy:

List Food allergies *

Describe reaction if this food is eaten and what is done to manage it *

Describe reaction to insect bite and what is done to manage it: *

List Medications that your child is allergic to *

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

Medication *

Child does not take any medication at home

Child takes the following medication at home

List Medications *

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

Yes

No

Please explain *

Child will take the following medication while at camp

Name of medication *

Reason for taking *

Dose taken *

Time to be taken during camp? *

Will your child be taking additional medication while at camp *

Name of medication *

Reason for taking *

Dose taken *

Time to be taken during camp? *

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.

Signature of parent/guardian or adult staff *

Date *

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

EIP

Please explain all checked answers, noting the number of the item. *

Immunization: (ACA requirement)

Are all required school immunizations up to date? *

Yes

No

Date of last Tetanus Booster

Month *

Day *

Year *

Mental and Emotional Health:

Mental and Emotional Health: (Explain ‘yes’ answers below)

	Yes
Attention Deficit Disorder (ADD) or ADHD	Yes
A psychiatric diagnosis such as depression, OCD,	Yes
An emotional health concern	Yes
A learning disability	Yes
Seen or is currently seeing a professional to address mental/emotional health concerns	Yes

Explain ‘yes’ answers

Restrictions:

Restrictions: Any restrictions to camp activities?

Please provide additional information about your child’s health which may have been neglected on this form.