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Camp Health Form

* Required Fields

Child
First Name: *
Last Name: *
Address *
Street: City:
State: Zip:
Age: Date of birth: (MM/DD/YYYY)
Height: ft   in Weight: lbs
Special Needs:

Parent(s) or Guardian (s):

First Name (#1): First Name (#2):
Last Name (#1): Last Name (#2):
Home Phone (#1): * Home Phone (#2):
Work Phone (#1): Work Phone (#2):
Cell Phone (#1): Cell Phone (#2):

In an emergency notify: *

First Name: Last Name:
Relationship

Emergency Contact Address
Street: City:
State: Zip:
Home Phone: * Work Phone: *
Cell Phone: *

Does your child have physical, medical or emotional problems? Yes   No

If yes, describe:

Does your child take any medications on a daily basis? Yes   No

If yes, list medications:

If your child needs to take medication during the camp day, the medicine should be labeled with your child's name and it will be forwarded to the nurse. To give your child any prescribed medication we need the following:

  1. Medication in its original container.
  2. Camper's name clearly labeled on the container.
  3. If the prescription is not in the original container please send in a doctor's note prescribing the medication with time and dosage.

I hereby request that my child, take medication during the camp day in the presence of the Nurse at Tall Pines Day Camp; including but not limited to administering epinephrine in case of a severe reaction or anaphylaxis.

Name of the medication:

Dosage of the medication:

Time and day medication is to be given:

Does your child have any known allergic reactions to the following?

Bee Sting
Peanuts
Chocolate
Penicillin

Other Foods:
Other Drugs:
Seasonal Allergens:
Other:

What is your child's usual reaction?

Hives
Rash
Anaphylaxis
Other  

Does the nurse have permission to administer Benadryl if needed for nonspecific rashes or minor allergic reactions?
Yes   No (Dosage based on child's age or weight.)

Does the nurse have permission to administer one of the following for headaches or minor discomforts? (select preference)   Yes   No

Tylenol
Motrin
Advil
Tums

Does your child need (select preference)   Liquid   Pill

HEALTH HISTORY:

Frequent Colds
Bed Wetting
Heart Trouble
Abscessed Ears
Athlete's Foot
Kidney Trouble
Measles
Whooping Cough
Convulsions
Stomach Upsets
Chicken Pox
Bronchitis
Sinusitis
Poliomyelitis
Sleep Walking
Frequent Sore Throats
Mumps
Constipation
Diabetes
Tuberculosis

Serious Ivy, Oak, Sumac Poisoning
Operations or Serious Injuries
Any Allergies
Emotional Stability: Much Some Little None
Maturity: Much Some Little None
Any Personal Problems: Much Some Little None
Any Behavior Problems: Explain:  
Any Learning Problems: Explain:  
Recommendations/Restrictions
(Diet, medicine, swimming, running, etc.):		 Explain:  

IMMUNIZATIONS:

(Write approx. date of immunization.)

DPT Series:
Tetanus:
Polio:
Measles (MMR):
Haemphilis (Hib):

Is child up to date with Tetanus vaccine or Tetanus booster shot? Yes   No


In case of emergency, I understand every effort will be made to contact parents/guardian of camper. In the event that I cannot be reached, I hereby give permission to the physician selected by the Director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child, as named above.

By checking the box you are agreeing to the terms above

Physician's Name:
Physician's Phone:
Date of Last Physical Exam:
Physician's Signature: Print your completed form after clicking submit and send it to us with your child physician's signature using one of the contact options at the bottom of the page.

Medical exam is not required by state law. Doctor's signature is only necessary if camper requires medical clearance to participate in camp activities.