Health FormHealth Form • June 24th, 2013
Camper InformationCamper Name __________________________________________ Birth Date ___ / ___ / ___ Age Gender M / FMonth Day YearStreet _______________________________________________ City ____________________ State _______ Zip _____________ Parent/Guardian 1_______________________________________ Home(___) ________ Work(___) _________ Cell(___) __________ Parent/Guardian 2________________________________________ Home(___) ________ Work(___) _________ Cell(___) __________ Emergency Contact________________________________________ Home(___) ________ Work(___) _________ Cell(___) __________ Please indicate if your child has had any of the fol- lowing injuries, conditions, or illnesses:□ Asthma □ GI Disorders □ Psychiatric□ Frequent □ Heart Problems Diagnosis Ear Infections □ ADD/ADHD □ Other ________□ Seizure □ Muscular/Disorder Skeletal Injury ________________□ Diabetes □ Sleepwalking Please record information about any items above; any significant medi- cal history; any hospitalization
DO NOT MAIL THIS HEALTH FORM AND BEHAVIOUR AGREEMENT BACK TO US, PLEASE BRING IT, SIGNED, TO THE CAMP W HEN YOU COME]Health Form • February 19th, 2020
(Daytime) (Evening) (Cell) Please note: All information on this form wll be treated as confidential. Please return this form to the camp at registration. We need this information to ensure your child receives proper health care. If there is not enough room below, please add an additional page. Camp policy states that all medication must be given to the camp first-aider or designate at registration. Send all medications your child requires on a regular basis, including inhalers and EpiPens. Please ensure dosage is clearly visible (original container, please).
