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Camp Health Form
Please be sure to notify the camp session
director if this camper is exposed to communicable disease or has suffered
injury during the three weeks prior to camp attendance.
Health and Accident Coverage
Camp users will be
covered by a health/accident policy that will pay for the first $250 of
health care, and the balance over that amount is collectible from camp
users' own insurance coverage up to policy limits.
Camper/Participant
__________________________________________________________ Birthdate
______________________
Age ______ Sex _____
Parent or Guardian (or
spouse) ______________________________________________ Home
Phone________________________
Relationship Area code and number
Home address
_____________________________________________________________________________________________
____________________________________________________________________________________________________________
Parent/Guardian Work; or
if not available, give other person to
contact
Phone
If not available in an
emergency notify:
___________________________________________________________________________________________________________
Name
Relationship
Phone
____________________________________________________________________________________________________________
Street and
Number
City
State Zip
____________________________________________________________________________________________________________
Insurance
Company Policy
No. Type ( ) group ( )
individual
____________________________________________________________________________________________________________
Name of Policy
Holder
Policyholder's Employer and Employer's Address
Parent/Guardian Social
Security Number ___________________________________(Requested by hospital)
AUTHORIZATION FOR MEDICAL TREATMENT
The undersigned parent/guardian/person authorizes the Illinois
Great Rivers United Methodist Conference to secure medical
treatment
for _____________________________________________ (name of
person) in case of any illness or accident for which the camp
director or first aid personnel feels professional medical
attention is required. I hereby give permission to the physician
selected by the camp director/first aid personnel to hospitalize,
secure proper treatment for, or to order injection, anesthesia or
surgery for me/my child as named.
_________________________________________________________________________________________________________
Signature of
Parent or
Guardian
Relationship Date
(or camper
if of legal age)
Family
Physician
______________________________________________________________________________________
Name
Phone number
Family
Physician Address
_______________________________________________________________________________
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Important! NO camper
under 18 years of age will be accepted at camp unless the following
section is fully completed. All campers are requested to complete this
form.
Please complete the
health history on the reverse side of this form as accurately as possible.
A health examination by a physician is only necessary if a camper has been
exposed to contagious disease or is recovering from severe injury or
illness. This information will enable a health care facility to treat
you/your child with minimum delays in case of an emergency.
HEALTH HISTORY:
(Check- giving approximate date)
Diseases:
Allergies: Please list below
Anorexia/bulimia
_________ Rheumatic Fever
_________
Asthma _________
Chicken Pox _________
Convulsions _________
German measles _________
Diabetes _________
Measles _________
Ear
Infections _________
Mumps _________
Hyperactive _________
Heart _________
Lethargic _________
Respiratory _________
Operations or serious injuries (dates)
____________________________________________________________
Chronic or recurring
illnesses and/or concerns of a physical or emotional nature (please be
specific).
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
IMMUNIZATION HISTORY
This is a record of
approximate dates of basic immunizations and most recent booster doses.
DPT Series ______________________________
Booster ____________ Tetanus booster __________________
Polio OPV (Sabin) ______________________
Booster ____________
Typhoid
________________________ Measles Vaccine (live)
_____________________ Tuberculin Test ________________
German Measles
(Rubella)
_______________ Mumps Vaccine (live) _______________
Smallpox ____________________
Other
___________________________________________________
GENERAL PHYSICAL CONDITION
Height ____________
Weight _____________
Eyes- ( ) Normal
( ) Glasses ( ) Contacts
Ears- ( ) Normal
( ) Hearing device ( ) Hard of Hearing
Hernia
___________________________________ Extremities _________________________
Posture (spine)
________________________________________________________________
Skin_________________________________________________________________________
Allergy (Please
specify) ________________________________________________________
General Appraisal
_____________________________________________________________
For Girls and Women
Has this person
menstruated? ____________________ If not, has she been told about
it?______________
If so, is her menstrual
history normal? ____________ Special Considerations
_________________________________________
Special Diet
__________________________________________________________________________________________
Special medicine including medication for emotional concerns (include name
of medication)
____________________________________________________________________________________________________
Is parent sending it?
( ) Yes ( ) No
Swimming, diving
permitted? ______________ Strenuous activity? ______________
Are you now (or within
the previous two years) receiving professional counseling for emotional
concerns? ( ) Yes ( ) No
If yes, briefly specify
_____________________________________________________________________________________
Other
________________________________________________________________________________________________
UPDATE AT TIME OF
ARRIVAL AT CAMP
•Has camper experienced
any medical problems within the last three weeks?
•Is camper still
recovering from any medical problem, injury, or accident?
•Is camper bringing any
medication? ( )
Yes ( ) No
Has Medication
Authorization Form been completed? ( )
Yes ( )
No
Signature of person
bringing child to camp if not parent
__________________________________________________________
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