Camp Health Form

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Camper Health Form

CAMP NAME(Required)

What camp are you attending?

Participant Name(Required)

First Last

Participant Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardians(Required)

First Name

Last Name

Best Contact Number

In case of emergency (injury or illness), if you are unable to be contacted, we should contact:(Required)

Name:

Relationship:

Phone:

Participants Allergies - List all allergies here:(Required)

Allergies

Reaction

Food | Medication | Insect | Environmental

Does participant have any condition(s) that require special consideration | accommodations?(Required)

Condition

Accommodations Needed

Physical | Medical | Mental

Does participant carry an emergency medication e.g. EpiPen or Inhaler?(Required)

YES

Emergency Medication Information(Required)

Medication:

RX Instructions:

Does participant know how to use/store?

Will your child need medications administered during camp time? (0800-1630)(Required)

YES

Medication List:(Required)

Medication:

Dosage:

Administration Time:

Parent/Guardian Signature(Required)