Day Camp Health History and OTC Medication Form

Name

Birthday

Gender

Age

Multi-line address

Country/Region

Address

City

Zip / Postal code

Parent/Guardian Names

Primary phone

Secondary Phone

Family medical/Hospital insurance carrier

Policy or group number

Emergency Contact #1

Relationship

Daytime Phone

Evening Phone

Emergency Contact #2

Relationship

Daytime Phone

Evening Phone

Health History Record (check all that apply)

Any restrictions concerning physical activities?

Yes

No

Please describe any conditions

Allergies

Food/Nuts

Insect Stings

Medicine/Drugs

Other/Specify

Special dietary restrictions?

Date of last Tetanus booster (year)

Please list any medications taken on a daily basis, including over-the-counter medications

Any other relevant health concerns?

Over the Counter Medication

According to our Day Camp Protocols and Health Care Procedures, our health care staff can administer certain types of over-the-counter (OTC) medications. In order for your camper to be able to receive these, we need to have a parent/guardian signature.

Unchecked boxes means camper MAY NOT receive that medication

Weight of child for dosage purposes

I/We verify that this health history is complete and accurate. My child has permission to engage in all prescribed activities, except as noted by me. In case of illness or injury, I/We give permission for her/him to receive first aid and to receive emergency medical treatment from a licensed physician, emergency medical services or other health professional. It is understood that all reasonable efforts will be made to contact the parent or guardian. I/We verify my child has my permission to receive the above mentioned over-the-counter medications.

Signature of Parent/Guardian

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